1710713714 NPI number — MOVE MOUNTAINS THERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710713714 NPI number — MOVE MOUNTAINS THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOVE MOUNTAINS THERAPY 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:
1710713714
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3863 HIGHWAY 138 SE UNIT 62
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKBRIDGE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30281-4143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-596-5919
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
718 BASSWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADONNA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-596-5919
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2024

Additional Information

Authorized Official

Authorized Official Last Name:
BOWERS
Authorized Official First Name:
CHASITY
Authorized Official Middle Name:
TORRY
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
901-596-5919

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1679253868 . This is a "MENTAL HEALTH THERAPY COUNSELING" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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