Provider Demographics
NPI:1891278321
Name:EVERLASTING PEACE COUNSELING AND SUPPORT SERVICES
Entity Type:Organization
Organization Name:EVERLASTING PEACE COUNSELING AND SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-464-8539
Mailing Address - Street 1:PO BOX 12225
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31917-2225
Mailing Address - Country:US
Mailing Address - Phone:706-464-8539
Mailing Address - Fax:
Practice Address - Street 1:2210 WYNNTON RD STE 206
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-5820
Practice Address - Country:US
Practice Address - Phone:706-464-4597
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004843OtherGEORGIA LICENSE NUMBER
AL2924OtherALABAMA LICENSE NUMBER