Healthcare Provider Details

I. General information

NPI: 1518515154
Provider Name (Legal Business Name): CANDRA THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5835 CAMPBELLTON RD SW STE 303
ATLANTA GA
30331-8014
US

IV. Provider business mailing address

5835 CAMPBELLTON RD SW STE 303
ATLANTA GA
30331-8014
US

V. Phone/Fax

Practice location:
  • Phone: 404-666-9261
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC010591
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: