Provider Demographics
NPI:1366730079
Name:MY EPIPHANY COUNSELING AND CONSULTATION SERVICES, LLC.
Entity type:Organization
Organization Name:MY EPIPHANY COUNSELING AND CONSULTATION SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEMEKA
Authorized Official - Middle Name:LASHAY
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:205-919-6327
Mailing Address - Street 1:809 KOHL DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7489
Mailing Address - Country:US
Mailing Address - Phone:678-263-8830
Mailing Address - Fax:678-782-5491
Practice Address - Street 1:120 MILLBROOK VILLAGE DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-3605
Practice Address - Country:US
Practice Address - Phone:678-263-8830
Practice Address - Fax:678-782-5491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-14
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 101YP2500X, 251B00000X, 101YA0400X, 261QM0801X
GA005233101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty