1720539562 NPI number — EXPANSION COUNSELING SERVICES, LLC

Table of content: (NPI 1720539562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720539562 NPI number — EXPANSION COUNSELING SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXPANSION COUNSELING SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720539562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 SUN VALLEY DRIVE D2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30076
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-910-9162
Provider Business Mailing Address Fax Number:
770-910-9768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 SUN VALLEY DRIVE D2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSWELL
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-910-9162
Provider Business Practice Location Address Fax Number:
770-910-9768
Provider Enumeration Date:
10/17/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MORMANT
Authorized Official First Name:
EBONI
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
770-910-9162

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 1184963357 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1720539562 . This is a "GROUP NPI" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 003275832A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".