Healthcare Provider Details

I. General information

NPI: 1194631309
Provider Name (Legal Business Name): PHILIP BRUCE NIEKRO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 GRIMES BRIDGE RD STE H
ROSWELL GA
30075-3900
US

IV. Provider business mailing address

1160 GRIMES BRIDGE RD STE H
ROSWELL GA
30075-3900
US

V. Phone/Fax

Practice location:
  • Phone: 404-965-2686
  • Fax:
Mailing address:
  • Phone: 404-965-2686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC017244
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: