Healthcare Provider Details

I. General information

NPI: 1790264901
Provider Name (Legal Business Name): OLIVIA GORDON-THOMAS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OLIVIA THOMAS LPC

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 HONEY CREEK CMNS SE
CONYERS GA
30013-5806
US

IV. Provider business mailing address

898 SWEET BRIAR TRL SE
CONYERS GA
30094-3854
US

V. Phone/Fax

Practice location:
  • Phone: 404-800-5255
  • Fax: 470-974-2125
Mailing address:
  • Phone: 404-800-5255
  • Fax: 470-974-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC014842
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014842
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: