=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841875333
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSCIOUS LIVING THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2021
-----------------------------------------------------
Last Update Date | 03/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1441 WOODMONT LN NW # 1988
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-604-7463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1441 WOODMONT LN NW # 1988
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30318-2866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-604-7463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. BRIAN AUSTIN TEAL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 901-604-7463
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------