Provider Demographics
NPI:1720854466
Name:AUTHENTIC SELF ASSOCIATION LLC
Entity Type:Organization
Organization Name:AUTHENTIC SELF ASSOCIATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:COTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CSAC, MSW, BSW
Authorized Official - Phone:757-918-3381
Mailing Address - Street 1:4404 EAGLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-8038
Mailing Address - Country:US
Mailing Address - Phone:757-918-3381
Mailing Address - Fax:
Practice Address - Street 1:4404 EAGLEBROOK DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-8038
Practice Address - Country:US
Practice Address - Phone:757-918-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty