Healthcare Provider Details

I. General information

NPI: 1952954844
Provider Name (Legal Business Name): MAURISA BRODSKY VERSEL LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 WINDERMERE PKWY STE 203
CUMMING GA
30041-7034
US

IV. Provider business mailing address

1827 POWERS FERRY RD SE BLDG 22
ATLANTA GA
30339-5621
US

V. Phone/Fax

Practice location:
  • Phone: 770-953-4744
  • Fax:
Mailing address:
  • Phone: 770-953-4744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003680
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: