Healthcare Provider Details

I. General information

NPI: 1093597627
Provider Name (Legal Business Name): SLATER THERAPEUTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 MAIN ST # 5
COLLEGE PARK GA
30337-3544
US

IV. Provider business mailing address

3703 MAIN ST # 5
COLLEGE PARK GA
30337-3544
US

V. Phone/Fax

Practice location:
  • Phone: 770-569-3224
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: AMANDA SLATER
Title or Position: OWNER/ COUNSELOR
Credential: LPC
Phone: 704-449-0792