MEDICARE: EPIPHANY COUNSELING GUIDANCE AND TREATMENT SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	14-000385	GA

General Provider Information

NPI Number	:	1114316676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EPIPHANY COUNSELING GUIDANCE AND TREATMENT SERVICES

Provider Business Mailing Address
First Line	:	8484 HIGHWAY 85
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30238-4308
Country	:	US
Telephone Number	:	678-788-7400
Fax Number	:	678-954-6896

Provider Business Practice Location Address
First Line	:	3555 MERCER UNIVERSITY DR
Second Line	:	SUITE 101-6
City	:	MACON
State	:	GA
Zip	:	31204-4940
Country	:	US
Telephone Number	:	678-788-7400
Fax Number	:	678-954-6896

Authorized Official
Title or Position	:	OWNER
Name	:	DENISE DIXON
Credential	:
Telephone Number	:	678-788-7400

Provider Enumeration Date	:	01/21/2015
Last Update Date	:	02/02/2015

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