Healthcare Provider Details

I. General information

NPI: 1720461973
Provider Name (Legal Business Name): GWINNETT COMPREHENSIVE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W CROGAN ST STE A
LAWRENCEVILLE GA
30046-3238
US

IV. Provider business mailing address

PO BOX 1654
LAWRENCEVILLE GA
30046-1654
US

V. Phone/Fax

Practice location:
  • Phone: 678-386-1895
  • Fax: 678-623-8300
Mailing address:
  • Phone: 678-386-1895
  • Fax: 678-623-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004369
License Number StateGA

VIII. Authorized Official

Name: KIM BROOKS
Title or Position: OWNER
Credential: LPC
Phone: 678-386-1895