Healthcare Provider Details

I. General information

NPI: 1386196871
Provider Name (Legal Business Name): RANDALL OVERDORFF, LPC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 DAWSONVILLE HWY STE 2201
GAINESVILLE GA
30501-2610
US

IV. Provider business mailing address

2038 PINE TREE CIR
GAINESVILLE GA
30501-1334
US

V. Phone/Fax

Practice location:
  • Phone: 678-936-4954
  • Fax: 770-534-9104
Mailing address:
  • Phone: 678-936-4954
  • Fax: 770-534-9104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC001347
License Number StateGA

VIII. Authorized Official

Name: RANDY OVERDORFF
Title or Position: OWNER
Credential: LPC
Phone: 770-339-7667