Healthcare Provider Details

I. General information

NPI: 1023405271
Provider Name (Legal Business Name): JOURNEY COUNSELING AND PSYHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2339 LAKE PARK DR
ALBANY GA
31707-3131
US

IV. Provider business mailing address

2339 LAKE PARK DR
ALBANY GA
31707-3131
US

V. Phone/Fax

Practice location:
  • Phone: 229-255-3099
  • Fax: 229-638-6302
Mailing address:
  • Phone: 229-255-3099
  • Fax: 229-638-6302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007520
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006319
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY002049
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DIANE CERJAN
Title or Position: LICENSED CLINICAL PSYCHOLOGIST
Credential: PSY.D.
Phone: 229-255-3099