Provider Demographics
NPI:1245079433
Name:HEBERT, MARQUIS TANISHA
Entity type:Individual
Prefix:
First Name:MARQUIS
Middle Name:TANISHA
Last Name:HEBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PLEASURE
Other - Middle Name:COACH
Other - Last Name:DIAMOND
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CERTIFIED SEXOLOGIST
Mailing Address - Street 1:1400 VETERANS MEMORIAL HWY SE STE 134-156
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2945
Mailing Address - Country:US
Mailing Address - Phone:770-569-3639
Mailing Address - Fax:
Practice Address - Street 1:1400 VETERANS MEMORIAL HWY SE STE 134-156
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126-2945
Practice Address - Country:US
Practice Address - Phone:770-569-3639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-20
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA23136101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor