Healthcare Provider Details

I. General information

NPI: 1811701899
Provider Name (Legal Business Name): CHARLOTTE WALLEN USSERY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 02/03/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3854 PINE NEEDLE DR
DULUTH GA
30096-2534
US

IV. Provider business mailing address

3854 PINE NEEDLE DR
DULUTH GA
30096-2534
US

V. Phone/Fax

Practice location:
  • Phone: 678-294-0011
  • Fax:
Mailing address:
  • Phone: 678-294-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003562
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: