Healthcare Provider Details

I. General information

NPI: 1639720923
Provider Name (Legal Business Name): MOLLY GEBHARDT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2019
Last Update Date: 11/27/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WESTPARK DR STE 130
PEACHTREE CITY GA
30269-1447
US

IV. Provider business mailing address

4321 HIGHWAY 166
DOUGLASVILLE GA
30135-5066
US

V. Phone/Fax

Practice location:
  • Phone: 770-310-6726
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number007062
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: