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General NPI Number Information
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NPI Number | 1922145325
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Entity Type | Organization
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Legal Business Name | MARVELOUS LIGHT CONSULTANTS
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 4484 COVINGTON HWY SUITE 100A
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City | DECATUR
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State | GA
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Zip | 30035-1203
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Country | US
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Telephone | 404-286-0054
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Fax | 404-286-0064
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Provider Business Mailing Address
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Address Line | PO BOX 1501
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City | LITHONIA
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State | GA
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Zip | 30058-1007
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Country | US
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Telephone | 404-286-0054
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Fax | 404-286-0064
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Authorized Official
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Title or Position | CEO
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Name | MRS. DEWANDA B. JACKSON
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Credential | MS LPC
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Telephone | 404-286-0054
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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 | LPC002390
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License Number State | GA
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