Provider Demographics
NPI:1396868824
Name:HEALTH REJUVENATIONS CONSULTANT, INC.
Entity type:Organization
Organization Name:HEALTH REJUVENATIONS CONSULTANT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:D'NIN
Authorized Official - Last Name:PATILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD LPC, CACII
Authorized Official - Phone:404-731-6107
Mailing Address - Street 1:4588 BOULDERCREST RD
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-3613
Mailing Address - Country:US
Mailing Address - Phone:404-731-6107
Mailing Address - Fax:404-366-9947
Practice Address - Street 1:194 JONESBORO RD
Practice Address - Street 2:SUITE A-6
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-4812
Practice Address - Country:US
Practice Address - Phone:404-731-6107
Practice Address - Fax:404-366-9947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1594101YA0400X
GA004196251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01068080OtherAMERIGROUP CORPORATION