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General NPI Number Information
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NPI Number | 1861972952
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Entity Type | Organization
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Legal Business Name | RECOVERY LGBT INC.
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Dates
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Enumeration Date | 08/17/2018
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Last Update Date | 08/17/2018
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Provider Practice Location Address
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Address Line | 3011 RAINBOW DR STE 308
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City | DECATUR
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State | GA
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Zip | 30034-1681
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Country | US
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Telephone | 404-769-1118
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Fax |
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Provider Business Mailing Address
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Address Line | 3011 RAINBOW DR STE 308
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City | DECATUR
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State | GA
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Zip | 30034-1681
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Country | US
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Telephone | 404-769-1118
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | J.D. WEIDNER
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Credential |
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Telephone | 404-769-1118
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC009051
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License Number State | GA
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