Healthcare Provider Details

I. General information

NPI: 1174685234
Provider Name (Legal Business Name): DAVID G ROUTLY MA LPC CPCS BC-TMH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2652 BACK CREEK CHASE
DACULA GA
30019-6849
US

IV. Provider business mailing address

2652 BACK CREEK CHASE
DACULA GA
30019-6849
US

V. Phone/Fax

Practice location:
  • Phone: 678-360-9639
  • Fax:
Mailing address:
  • Phone: 678-360-9639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC001386
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: