Provider Demographics
NPI:1871007161
Name:EXPANSION GUIDANCE SERVICES
Entity Type:Organization
Organization Name:EXPANSION GUIDANCE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EBONI
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-609-1973
Mailing Address - Street 1:760 OLD ROSWELL RD STE 208
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-8686
Mailing Address - Country:US
Mailing Address - Phone:770-609-1973
Mailing Address - Fax:770-545-8630
Practice Address - Street 1:760 OLD ROSWELL RD STE 208
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-8686
Practice Address - Country:US
Practice Address - Phone:770-609-1973
Practice Address - Fax:770-545-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-22
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006759251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health