Healthcare Provider Details

I. General information

NPI: 1376133223
Provider Name (Legal Business Name): TALINA RODRIGUEZ LANDESTOY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 03/15/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 EVANS MILL RD
LITHONIA GA
30038-2481
US

IV. Provider business mailing address

2910 EVANS MILL RD # B83
LITHONIA GA
30038-2481
US

V. Phone/Fax

Practice location:
  • Phone: 404-500-8387
  • Fax:
Mailing address:
  • Phone: 404-788-8094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1403
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC007677
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: