Provider Demographics
NPI:1487888566
Name:IMANI HOUSE LLC
Entity type:Organization
Organization Name:IMANI HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROFESSIONAL COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, EDD,CADC, NCC
Authorized Official - Phone:706-825-8472
Mailing Address - Street 1:1227 AUGUSTA WEST PKWY STE 8
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6671
Mailing Address - Country:US
Mailing Address - Phone:706-825-9051
Mailing Address - Fax:706-860-1850
Practice Address - Street 1:1227 AUGUSTA WEST PKWY STE 8
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6671
Practice Address - Country:US
Practice Address - Phone:706-825-9051
Practice Address - Fax:706-860-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-05
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18226251S00000X
GALPC004458251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172613501Medicaid
GA184952006AMedicaid