Basic Information
| Provider Information | |||||||||
| NPI: | 1659004299 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COURAGEOUS INTENTIONS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5710 OGEECHEE RD | ||||||||
| Address2: | STE 200-238 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314059515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238028115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 53 POMONA CIRCLE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314198190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238028115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2022 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | LITTLE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4238028115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1326487034 | 01 | CO | NPI | OTHER | 1326487034 | 01 | GA | NPI | OTHER |