Provider Demographics
NPI:1396194163
Name:PROVIDENCE COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:PROVIDENCE COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:808-248-5153
Mailing Address - Street 1:3626 STEINHAUER RD NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4755
Mailing Address - Country:US
Mailing Address - Phone:678-248-5153
Mailing Address - Fax:
Practice Address - Street 1:1301 SHILOH RD NW
Practice Address - Street 2:STE 840
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7147
Practice Address - Country:US
Practice Address - Phone:678-942-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-12
Last Update Date:2016-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty