Healthcare Provider Details

I. General information

NPI: 1700316635
Provider Name (Legal Business Name): SIMON FRAGAKIS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 PIEDMONT RD NE STE 350
ATLANTA GA
30305-1582
US

IV. Provider business mailing address

3227 HABERSHAM RD NW
ATLANTA GA
30305-1162
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-2008
  • Fax:
Mailing address:
  • Phone: 404-313-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: