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General NPI Number Information
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NPI Number | 1811292477
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Entity Type | Organization
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Legal Business Name | PORT OF PEACE COUNSELING LLC
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Dates
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Enumeration Date | 01/12/2011
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Last Update Date | 01/12/2011
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Provider Practice Location Address
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Address Line | 8305 OFFICE PARK DR B
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-6935
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Country | US
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Telephone | 404-291-8931
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1262
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City | LITHIA SPRINGS
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State | GA
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Zip | 30122-1165
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Country | US
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Telephone | 404-291-8931
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | MARIE-VIOLENE MERTILUS
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Credential | LCSW
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Telephone | 404-291-8931
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | CSW004124
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License Number State | GA
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