Healthcare Provider Details

I. General information

NPI: 1578900122
Provider Name (Legal Business Name): KELLY CAMARATA M.ED, LPC,CAADC, SA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 ATLANTA ST SUITE #5-B
MCDONOUGH GA
30253-2162
US

IV. Provider business mailing address

201 MARGIE CT
MCDONOUGH GA
30252-3105
US

V. Phone/Fax

Practice location:
  • Phone: 678-758-5578
  • Fax:
Mailing address:
  • Phone: 404-277-3747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC0168
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008262
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: