Healthcare Provider Details

I. General information

NPI: 1912270844
Provider Name (Legal Business Name): ELSA VICENTE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/18/2020
Certification Date: 02/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4006 HIGHWAY 34 E
SHARPSBURG GA
30277-3531
US

IV. Provider business mailing address

4006 HIGHWAY 34 E
SHARPSBURG GA
30277-3531
US

V. Phone/Fax

Practice location:
  • Phone: 404-960-1282
  • Fax:
Mailing address:
  • Phone: 404-960-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006722
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: