MEDICARE: CENTER FOR VICTIMS OF TORTURE

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	101YM0800X	Mental Health Counselor
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1952253825
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR VICTIMS OF TORTURE

Provider Business Mailing Address
First Line	:	4020 E PONCE DE LEON AVE
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-1815
Country	:	US
Telephone Number	:	470-545-2776
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 E PONCE DE LEON AVE
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-1815
Country	:	US
Telephone Number	:	470-545-2776
Fax Number	:

Authorized Official
Title or Position	:	BILLER
Name	:	KA THAO
Credential	:
Telephone Number	:	612-436-4860

Provider Enumeration Date	:	02/12/2026
Last Update Date	:	02/12/2026

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Directions to “CENTER FOR VICTIMS OF TORTURE ” Practice Location

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