Healthcare Provider Details

I. General information

NPI: 1710937099
Provider Name (Legal Business Name): COUNSELING & PSYCHIATRY OF GWINNETT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 770-978-9393
  • Fax: 770-978-9324
Mailing address:
  • Phone: 770-978-9393
  • Fax: 770-978-9324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number045522
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000290
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT000665
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number001166
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW03196
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7799
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7551
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7753
License Number StateGA
# 9
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number040961
License Number StateGA

VIII. Authorized Official

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