Provider Demographics
NPI:1215288097
Name:REBUILDING LIVES COUNSELING AND CONSULTING LLC
Entity type:Organization
Organization Name:REBUILDING LIVES COUNSELING AND CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO- FOUNDER
Authorized Official - Prefix:MS
Authorized Official - First Name:NEDRA
Authorized Official - Middle Name:TAMARA
Authorized Official - Last Name:PENLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-835-8144
Mailing Address - Street 1:POST OFFICE BOX 465873
Mailing Address - Street 2:35 PATTERSON RD.
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30042
Mailing Address - Country:US
Mailing Address - Phone:678-835-8144
Mailing Address - Fax:
Practice Address - Street 1:4411 SUWANEE DAM RD
Practice Address - Street 2:SUITE 635
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-8701
Practice Address - Country:US
Practice Address - Phone:678-835-8144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005762101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006862116AMedicaid