Healthcare Provider Details

I. General information

NPI: 1700598018
Provider Name (Legal Business Name): MARINA ROSE PATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 MEDLOCK BRIDGE RD STE 101
JOHNS CREEK GA
30097-8455
US

IV. Provider business mailing address

1880 MAPLE DR APT 1136
KENNESAW GA
30144-1743
US

V. Phone/Fax

Practice location:
  • Phone: 404-282-1196
  • Fax:
Mailing address:
  • Phone: 706-223-8847
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC016718
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: