Healthcare Provider Details

I. General information

NPI: 1952408213
Provider Name (Legal Business Name): INSIDEOUT DYNAMICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 GOVERNORS SQ STE A
FAYETTEVILLE GA
30215-4862
US

IV. Provider business mailing address

130 GOVERNORS SQ STE A
FAYETTEVILLE GA
30215-4862
US

V. Phone/Fax

Practice location:
  • Phone: 678-364-1300
  • Fax: 678-364-1352
Mailing address:
  • Phone: 678-364-1300
  • Fax: 678-364-1352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003094
License Number StateGA

VIII. Authorized Official

Name: MRS. LINDA C WEIGAND
Title or Position: OWNER / PROFESSIONAL COUNSELOR
Credential: M.A,, L.P.C.
Phone: 678-364-1300