Healthcare Provider Details

I. General information

NPI: 1780982249
Provider Name (Legal Business Name): O ANITA BRACKETT LPC006323
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 WASHINGTON ST STE 212
CLARKESVILLE GA
30523-5430
US

IV. Provider business mailing address

160 THREE SISTERS TRL
CLEVELAND GA
30528-7289
US

V. Phone/Fax

Practice location:
  • Phone: 706-809-8601
  • Fax: 706-865-5358
Mailing address:
  • Phone: 706-809-8601
  • Fax: 706-865-5358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006323
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: