Healthcare Provider Details

I. General information

NPI: 1134048499
Provider Name (Legal Business Name): AMY VAN HAVEREN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY LEE PRICE

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 TRIBBLE GAP RD
CUMMING GA
30040-2475
US

IV. Provider business mailing address

3357 LAKEWIND WAY
ALPHARETTA GA
30005-4203
US

V. Phone/Fax

Practice location:
  • Phone: 770-404-6135
  • Fax:
Mailing address:
  • Phone: 404-272-6763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC000481
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: