Provider Demographics
NPI:1033556659
Name:BLACK SWAN ENTERPRISES
Entity Type:Organization
Organization Name:BLACK SWAN ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, LEAD THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MIKAELA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:HEARD
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC
Authorized Official - Phone:404-832-0604
Mailing Address - Street 1:1313 OAK ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1653
Mailing Address - Country:US
Mailing Address - Phone:678-748-0128
Mailing Address - Fax:
Practice Address - Street 1:2801 BUFORD HWY NE
Practice Address - Street 2:STE 501
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2149
Practice Address - Country:US
Practice Address - Phone:404-832-0604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007304101YP2500X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty