=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851177109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RECOVERY LGBT COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2023
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2750 HERITAGE MANOR WALK
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-317-9566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2750 HERITAGE MANOR WALK
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-317-9566
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JD WEIDNER
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 404-317-9566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------