Provider Demographics
NPI:1184025587
Name:HEAVENLY THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:HEAVENLY THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC
Authorized Official - Prefix:
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:DARNELL
Authorized Official - Last Name:BLOCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-946-2312
Mailing Address - Street 1:110 HABERSHAM DR
Mailing Address - Street 2:STE 116
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1381
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 HABERSHAM DR
Practice Address - Street 2:STE 116
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1381
Practice Address - Country:US
Practice Address - Phone:770-946-2312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty