Healthcare Provider Details

I. General information

NPI: 1558084368
Provider Name (Legal Business Name): TARA WOJTKUNSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 SPENCER AVE
EAST POINT GA
30344-2704
US

IV. Provider business mailing address

1310 SPENCER AVE
EAST POINT GA
30344-2704
US

V. Phone/Fax

Practice location:
  • Phone: 470-344-9932
  • Fax:
Mailing address:
  • Phone: 470-344-9932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number009865
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: