Provider Demographics
NPI:1114425204
Name:AGAPE TRANSFORMATION PRACTICE
Entity Type:Organization
Organization Name:AGAPE TRANSFORMATION PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KARRION
Authorized Official - Middle Name:D
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-753-5248
Mailing Address - Street 1:4978 RIVER OVERLOOK WAY
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-6234
Mailing Address - Country:US
Mailing Address - Phone:678-753-5248
Mailing Address - Fax:404-585-3054
Practice Address - Street 1:235 E PONCE DE LEON AVE STE 103
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3412
Practice Address - Country:US
Practice Address - Phone:678-753-5248
Practice Address - Fax:404-585-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006638101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty