MEDICARE: ONE-EIGHTY COUNSELING PRACTICE

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)	LPC009559	GA

General Provider Information

NPI Number	:	1982112231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONE-EIGHTY COUNSELING PRACTICE

Provider Business Mailing Address
First Line	:	PO BOX 82567
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30354-0567
Country	:	US
Telephone Number	:	678-836-9263
Fax Number	:	678-927-9355

Provider Business Practice Location Address
First Line	:	1003 VIRGINIA AVE STE 212
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30354-1387
Country	:	US
Telephone Number	:	678-836-9263
Fax Number	:	678-927-9355

Authorized Official
Title or Position	:	THERAPIST
Name	:	MRS. DEANA JO VIVIAN
Credential	:	LPC
Telephone Number	:	678-836-9263

Provider Enumeration Date	:	01/19/2018
Last Update Date	:	01/19/2018

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