Healthcare Provider Details

I. General information

NPI: 1093029019
Provider Name (Legal Business Name): FRESH START COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 MYRTLE CROSSING DR SUITE 200
STATESBORO GA
30458-4429
US

IV. Provider business mailing address

326 MYRTLE CROSSING DR SUITE 200
STATESBORO GA
30458-4429
US

V. Phone/Fax

Practice location:
  • Phone: 912-489-7590
  • Fax: 912-489-3877
Mailing address:
  • Phone: 912-489-7590
  • Fax: 912-489-3877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC005560
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT000892
License Number StateGA

VIII. Authorized Official

Name: CYNTHIA LEE
Title or Position: PARTNER
Credential: LPC
Phone: 912-486-7590