Healthcare Provider Details

I. General information

NPI: 1275618449
Provider Name (Legal Business Name): DARRIN SAMUEL BRONFMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4530 S BERKELEY LAKE RD B
NORCROSS GA
30071-1660
US

IV. Provider business mailing address

4530 S BERKELEY LAKE RD B
NORCROSS GA
30071-1660
US

V. Phone/Fax

Practice location:
  • Phone: 770-446-5642
  • Fax: 770-446-5643
Mailing address:
  • Phone: 770-446-5642
  • Fax: 770-446-5643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003592
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: