MEDICARE: INSIDE OUT RELATIONSHIP MAKEOVER SERVICES, LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1588355432
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSIDE OUT RELATIONSHIP MAKEOVER SERVICES, LLC

Provider Business Mailing Address
First Line	:	1954 AIRPORT RD # 1643
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-4956
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1954 AIRPORT RD # 1643
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30341-4956
Country	:	US
Telephone Number	:	630-272-1897
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST/CEO
Name	:	SHAVONNA NICOLE PETERSON
Credential	:	LPC
Telephone Number	:	630-272-1897

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/19/2023

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