Healthcare Provider Details

I. General information

NPI: 1881622918
Provider Name (Legal Business Name): JOHN ENDRESS L.P.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 ALABAMA AVE
BREMEN GA
30110-2005
US

IV. Provider business mailing address

405 ALABAMA AVE
BREMEN GA
30110-2005
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-2367
  • Fax: 770-537-1203
Mailing address:
  • Phone: 770-537-2367
  • Fax: 770-537-1203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1469
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: