=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770089153
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IN-TO-MATE COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2018
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2751 BUFORD HWY NE STE 700
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30324-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-919-5016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 928 HUNTCLIFF VILLAGE CT
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30350-7515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SHAMIKA ALFORD
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 678-296-7861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | LPC009555
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------