Provider Demographics
NPI:1700550621
Name:IMPACT COACHING, CONSULTING, AND COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:IMPACT COACHING, CONSULTING, AND COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIATHE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-615-8769
Mailing Address - Street 1:6405 CRESTED EAGLE LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23231-5790
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4508 S LABURNUM AVE STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23231-2476
Practice Address - Country:US
Practice Address - Phone:804-615-8769
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty