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General NPI Number Information
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NPI Number | 1912252313
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Entity Type | Organization
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Legal Business Name | KEYS TO WOMEN'S WELLNESS LLC
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Dates
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Enumeration Date | 07/23/2012
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Last Update Date | 03/02/2017
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Provider Practice Location Address
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Address Line | 2283 NOTTLEY WALK
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City | MARIETTA
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State | GA
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Zip | 30066-8610
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Country | US
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Telephone | 770-502-5593
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Fax | 866-310-1591
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Provider Business Mailing Address
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Address Line | 2283 NOTTLEY WALK
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City | MARIETTA
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State | GA
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Zip | 30066-8610
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Country | US
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Telephone | 770-502-5593
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Fax | 866-310-1591
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Authorized Official
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Title or Position | OWNER
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Name | FANIKE KIARA OLUGBALA
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Credential | LCSW
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Telephone | 770-502-5593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | CSW004694
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License Number State | GA
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