Healthcare Provider Details

I. General information

NPI: 1124965942
Provider Name (Legal Business Name): FERN HAVEN COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 MAPLE ST STE 100
CARROLLTON GA
30117-3259
US

IV. Provider business mailing address

816 ROME ST
CARROLLTON GA
30117-2235
US

V. Phone/Fax

Practice location:
  • Phone: 770-467-3369
  • Fax:
Mailing address:
  • Phone: 770-467-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: ROBIN GORDON
Title or Position: OWNER
Credential: LPC
Phone: 770-467-3369