Healthcare Provider Details

I. General information

NPI: 1619708831
Provider Name (Legal Business Name): VICTORIA TAYLOR EADES LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1758 CENTURY BLVD NE STE B
ATLANTA GA
30345-3392
US

IV. Provider business mailing address

2988 STONEGATE TRL
ATLANTA GA
30340-5028
US

V. Phone/Fax

Practice location:
  • Phone: 770-354-2186
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC014454
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: