Healthcare Provider Details

I. General information

NPI: 1528628609
Provider Name (Legal Business Name): JONATHAN DEL VALLE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 PEACHTREE INDUSTRIAL BLVD STE 4201
BERKELEY LAKE GA
30071-5738
US

IV. Provider business mailing address

5311 TOWNE LAKE HTS # 5311
WOODSTOCK GA
30189-4252
US

V. Phone/Fax

Practice location:
  • Phone: 404-900-9583
  • Fax:
Mailing address:
  • Phone: 470-223-2409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12110
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW010530
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: