Provider Demographics
NPI:1669934030
Name:ONE WELLNESS BOUTIQUE, INC.
Entity type:Organization
Organization Name:ONE WELLNESS BOUTIQUE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:QUE'ANA
Authorized Official - Middle Name:LACHE
Authorized Official - Last Name:MORRIS JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-789-4079
Mailing Address - Street 1:931 MONROE DR NE STE A102-450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1793
Mailing Address - Country:US
Mailing Address - Phone:404-789-4079
Mailing Address - Fax:877-833-3855
Practice Address - Street 1:931 MONROE DR NE STE A102-450
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1793
Practice Address - Country:US
Practice Address - Phone:404-789-4079
Practice Address - Fax:877-833-3855
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONE WELLNESS BOUTIQUE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1972856805Medicaid