Healthcare Provider Details

I. General information

NPI: 1851702146
Provider Name (Legal Business Name): MEGAN ELIZABETH KUDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN ELIZABETH HOLLOWAY

II. Dates (important events)

Enumeration Date: 05/08/2014
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1095 STATE ST NW
ATLANTA GA
30318-5372
US

IV. Provider business mailing address

1095 STATE ST NW
ATLANTA GA
30318-5372
US

V. Phone/Fax

Practice location:
  • Phone: 407-718-9791
  • Fax:
Mailing address:
  • Phone: 407-718-9791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC009070
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: