Healthcare Provider Details

I. General information

NPI: 1720348188
Provider Name (Legal Business Name): MARCIA C HENNESSEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARCIA C HENNESSEY LCSW

II. Dates (important events)

Enumeration Date: 05/20/2012
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARKET PLACE BLVD SUITE 201
CARTERSVILLE GA
30121-8718
US

IV. Provider business mailing address

204 PROFESSIONAL CT SE
CALHOUN GA
30701-7020
US

V. Phone/Fax

Practice location:
  • Phone: 706-625-5900
  • Fax:
Mailing address:
  • Phone: 706-625-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC0148
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004615
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: