Provider Demographics
NPI:1720454572
Name:BEYOND COUNSELING AND WELLNESS, LLC
Entity type:Organization
Organization Name:BEYOND COUNSELING AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERMAINE
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:407-694-8704
Mailing Address - Street 1:495 ABBOTTS MILL DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8431
Mailing Address - Country:US
Mailing Address - Phone:770-742-9412
Mailing Address - Fax:
Practice Address - Street 1:495 ABBOTTS MILL DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-8431
Practice Address - Country:US
Practice Address - Phone:770-742-9412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0055321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty