Healthcare Provider Details

I. General information

NPI: 1346835287
Provider Name (Legal Business Name): APHRODITISE CORELLE EDGE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2021
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 COURTEAY DR NE
ATLANTA GA
30306
US

IV. Provider business mailing address

801 MARDEN CT SE
SMYRNA GA
30082-4348
US

V. Phone/Fax

Practice location:
  • Phone: 404-875-4551
  • Fax:
Mailing address:
  • Phone: 706-358-7663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC006664
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC012075
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: