Healthcare Provider Details

I. General information

NPI: 1982372074
Provider Name (Legal Business Name): CHARMAINE WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/02/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 AUTRY STREET NW
NORCROSS GA
30071-1919
US

IV. Provider business mailing address

4517 TERESA CT
LITHONIA GA
30038-7702
US

V. Phone/Fax

Practice location:
  • Phone: 770-464-5123
  • Fax:
Mailing address:
  • Phone: 770-712-5427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC005917
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: