Provider Demographics
NPI:1033518048
Name:MAUVESCAPE LLC
Entity Type:Organization
Organization Name:MAUVESCAPE LLC
Other - Org Name:MAUVESCAPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANTEA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-701-9559
Mailing Address - Street 1:675 SEMINOLE AVE NE STE 307
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-3416
Mailing Address - Country:US
Mailing Address - Phone:678-701-9559
Mailing Address - Fax:
Practice Address - Street 1:675 SEMINOLE AVE NE STE 307
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-3416
Practice Address - Country:US
Practice Address - Phone:678-701-9559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003998103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty