Healthcare Provider Details

I. General information

NPI: 1821451683
Provider Name (Legal Business Name): VICTORIA LEFTRIDGE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 CHURCH ST
DECATUR GA
30030-2515
US

IV. Provider business mailing address

1402 WENLOCK EDGE CV
STONE MOUNTAIN GA
30083-1233
US

V. Phone/Fax

Practice location:
  • Phone: 404-977-5182
  • Fax: 404-589-1615
Mailing address:
  • Phone: 404-977-5182
  • Fax: 404-589-9040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC010403
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC005080
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: