Healthcare Provider Details

I. General information

NPI: 1104056456
Provider Name (Legal Business Name): JANNAH S GOODELL LCSW, LPC, ATR-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SUMMIT POINTE WAY NE
ATLANTA GA
30329-4063
US

IV. Provider business mailing address

1010 SUMMIT POINTE WAY NE
ATLANTA GA
30329-4063
US

V. Phone/Fax

Practice location:
  • Phone: 678-733-2728
  • Fax:
Mailing address:
  • Phone: 678-733-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005371
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004122
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number90-062
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: