Provider Demographics
NPI:1720539562
Name:EXPANSION COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:EXPANSION COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:EBONI
Authorized Official - Middle Name:R
Authorized Official - Last Name:MORMANT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CPCS
Authorized Official - Phone:770-910-9162
Mailing Address - Street 1:500 SUN VALLEY DRIVE D2
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076
Mailing Address - Country:US
Mailing Address - Phone:770-910-9162
Mailing Address - Fax:770-910-9768
Practice Address - Street 1:500 SUN VALLEY DRIVE D2
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076
Practice Address - Country:US
Practice Address - Phone:770-910-9162
Practice Address - Fax:770-910-9768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X, 103TC0700X, 1041C0700X, 106H00000X, 106S00000X, 163WC1500X, 163WP0808X, 251S00000X
GA1184963357251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
No163WC1500XNursing Service ProvidersRegistered NurseCommunity HealthGroup - Single Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1720539562OtherGROUP NPI
GA003275832AMedicaid