Healthcare Provider Details

I. General information

NPI: 1366610479
Provider Name (Legal Business Name): AMY LOU KRATCOSKI LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY LOU JOHNSON LCSW

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CUMBERLAND PKWY SE
ATLANTA GA
30339-3915
US

IV. Provider business mailing address

3495 PIEDMONT RD NE
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-431-4100
  • Fax:
Mailing address:
  • Phone: 404-364-7285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: