MEDICARE: ONTHATILE ANGEL BROOKS LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	MFT002150	GA

General Provider Information

NPI Number	:	1477378305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ONTHATILE ANGEL BROOKS LMFT

Provider Business Mailing Address
First Line	:	3103 MOUNTAIN SHADOW WAY
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-4479
Country	:	US
Telephone Number	:	470-821-7856
Fax Number	:

Provider Business Practice Location Address
First Line	:	3103 MOUNTAIN SHADOW WAY
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30064-4479
Country	:	US
Telephone Number	:	470-821-7856
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2024
Last Update Date	:	11/15/2024

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