Healthcare Provider Details

I. General information

NPI: 1477734515
Provider Name (Legal Business Name): CARLA, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 11/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 MANSELL CT SUITE 100
ROSWELL GA
30076-1523
US

IV. Provider business mailing address

1049 WILEY BRIDGE RD
WOODSTOCK GA
30188-4604
US

V. Phone/Fax

Practice location:
  • Phone: 678-357-6928
  • Fax:
Mailing address:
  • Phone: 678-357-6928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberLPC000869
License Number StateGA

VIII. Authorized Official

Name: MRS. CAROL ANN MARRA
Title or Position: CEO
Credential: LPC
Phone: 678-357-6928