Provider Demographics
NPI:1659087351
Name:BLACK BUTTERFLY QUEENS LIFE COACHING LLC
Entity Type:Organization
Organization Name:BLACK BUTTERFLY QUEENS LIFE COACHING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:WINTERS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:770-282-9323
Mailing Address - Street 1:1244 HIGHWAY 138 SW # 1066
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1402
Mailing Address - Country:US
Mailing Address - Phone:770-282-9323
Mailing Address - Fax:
Practice Address - Street 1:320 LANIER AVE W STE 240
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7547
Practice Address - Country:US
Practice Address - Phone:770-282-9323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty