Healthcare Provider Details

I. General information

NPI: 1265597165
Provider Name (Legal Business Name): MONETA HUDDLESTON SINCLAIR MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 TAYLOR ST SW SUITE A
CONYERS GA
30012-5357
US

IV. Provider business mailing address

1113 PALMER TRL
LITHONIA GA
30058-9093
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-6677
  • Fax: 770-918-6686
Mailing address:
  • Phone: 678-793-0053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC04656
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: