Healthcare Provider Details

I. General information

NPI: 1508344581
Provider Name (Legal Business Name): SOUTH RIVER COUNSELING & CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1430 STARCREST DR NE
CONYERS GA
30012-3830
US

IV. Provider business mailing address

1430 STARCREST DR NE
CONYERS GA
30012-3830
US

V. Phone/Fax

Practice location:
  • Phone: 470-252-8270
  • Fax: 470-252-8270
Mailing address:
  • Phone: 470-252-8270
  • Fax: 470-252-8270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC007661
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW002086
License Number StateGA

VIII. Authorized Official

Name: MS. FRANCES JILL OLDHAM
Title or Position: THERAPIST/OWNER
Credential: LPC, NCC
Phone: 770-337-8591