Healthcare Provider Details

I. General information

NPI: 1376473264
Provider Name (Legal Business Name): JUAN LA FARRELL EDGAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 WHITLOCK AVE SW STE G6
MARIETTA GA
30064-4653
US

IV. Provider business mailing address

4180 MOUNT PARAN DR
SOCIAL CIRCLE GA
30025-3710
US

V. Phone/Fax

Practice location:
  • Phone: 470-338-3488
  • Fax:
Mailing address:
  • Phone: 470-269-9986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: