Healthcare Provider Details

I. General information

NPI: 1558379867
Provider Name (Legal Business Name): AUGUSTA H OLATIDOYE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 FAIRBURN RD SW
ATLANTA GA
30331-1907
US

IV. Provider business mailing address

5105 GLORE RD SW
MABLETON GA
30126-2053
US

V. Phone/Fax

Practice location:
  • Phone: 404-691-9627
  • Fax: 404-691-9793
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003752
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: