Healthcare Provider Details

I. General information

NPI: 1417875758
Provider Name (Legal Business Name): CARLY ANN SACKELLARES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PILGRIM VILLAGE DR STE 300
CUMMING GA
30040-9232
US

IV. Provider business mailing address

6038 GABLES LN APT 6038
SANDY SPRINGS GA
30350-5036
US

V. Phone/Fax

Practice location:
  • Phone: 678-740-3022
  • Fax:
Mailing address:
  • Phone: 770-846-0128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW010402
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: