Provider Demographics
NPI:1922145325
Name:MARVELOUS LIGHT CONSULTANTS
Entity Type:Organization
Organization Name:MARVELOUS LIGHT CONSULTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEWANDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS LPC
Authorized Official - Phone:404-286-0054
Mailing Address - Street 1:PO BOX 1501
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1007
Mailing Address - Country:US
Mailing Address - Phone:404-286-0054
Mailing Address - Fax:404-286-0064
Practice Address - Street 1:4484 COVINGTON HWY
Practice Address - Street 2:SUITE 100A
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-1203
Practice Address - Country:US
Practice Address - Phone:404-286-0054
Practice Address - Fax:404-286-0064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC002390101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty