Healthcare Provider Details

I. General information

NPI: 1720697469
Provider Name (Legal Business Name): CAROLYN MASSENGALE MORELAND LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2020
Last Update Date: 09/18/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 GOVERNORS SQ STE D
PEACHTREE CITY GA
30269-4871
US

IV. Provider business mailing address

4255 WADE GREEN RD NW STE 414
KENNESAW GA
30144-1763
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax:
Mailing address:
  • Phone: 770-265-4670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009981
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: