Healthcare Provider Details

I. General information

NPI: 1609871631
Provider Name (Legal Business Name): JULIE SHORTRIDGE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JULIE BOBLENZ MA, LPC, LSW

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5991 PARKWAY NORTH BLVD STE B4
CUMMING GA
30040-1342
US

IV. Provider business mailing address

PO BOX 2927
CUMMING GA
30028-6512
US

V. Phone/Fax

Practice location:
  • Phone: 404-274-5209
  • Fax: 770-818-5607
Mailing address:
  • Phone: 404-274-5209
  • Fax: 770-818-5607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003547
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS-0008535
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: