Provider Demographics
NPI:1588253280
Name:BOUNDLESS LOVE PSYCHOTHERAPY, LLC
Entity type:Organization
Organization Name:BOUNDLESS LOVE PSYCHOTHERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:DELICIA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-250-6026
Mailing Address - Street 1:34 STEEPLE CHASE TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-8305
Mailing Address - Country:US
Mailing Address - Phone:470-985-6858
Mailing Address - Fax:678-669-1898
Practice Address - Street 1:34 STEEPLE CHASE TRL
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132-8305
Practice Address - Country:US
Practice Address - Phone:470-985-6858
Practice Address - Fax:678-669-1898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-16
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA011523OtherLPC
GA1942823901Medicaid