Provider Demographics
NPI:1629896790
Name:BOSS LADY SWAG LLC
Entity type:Organization
Organization Name:BOSS LADY SWAG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TOMEKIA
Authorized Official - Middle Name:HOLANDIA
Authorized Official - Last Name:RAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-202-8812
Mailing Address - Street 1:125 JENNINGS MILL PKWY APT 1202
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7458
Mailing Address - Country:US
Mailing Address - Phone:706-338-9345
Mailing Address - Fax:
Practice Address - Street 1:125 JENNINGS MILL PKWY APT 1202
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7458
Practice Address - Country:US
Practice Address - Phone:706-338-9345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-28
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty