Healthcare Provider Details

I. General information

NPI: 1114102779
Provider Name (Legal Business Name): GWINNETT PSYCHOTHERAPY AND PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 HENRY CLOWER BLVD STE A
SNELLVILLE GA
30078-3152
US

IV. Provider business mailing address

2301 HENRY CLOWER BLVD STE A
SNELLVILLE GA
30078-3152
US

V. Phone/Fax

Practice location:
  • Phone: 770-978-9393
  • Fax:
Mailing address:
  • Phone: 770-978-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. LINDA M ANDERSON
Title or Position: CEO
Credential: LMFT
Phone: 770-978-9393