Healthcare Provider Details

I. General information

NPI: 1437408127
Provider Name (Legal Business Name): CROSBY MITCHELL COUNSELING SERVICES LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W SOLOMON ST SUITE 210
GRIFFIN GA
30223-3038
US

IV. Provider business mailing address

315 W SOLOMON ST SUITE 210
GRIFFIN GA
30223-3038
US

V. Phone/Fax

Practice location:
  • Phone: 770-233-2809
  • Fax: 770-233-2810
Mailing address:
  • Phone: 770-233-2809
  • Fax: 770-233-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0406
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC002290
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC001607
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001185
License Number StateGA

VIII. Authorized Official

Name: ANGELA OREM
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-233-2809