Healthcare Provider Details

I. General information

NPI: 1225771827
Provider Name (Legal Business Name): KHADIJAH HARDIMAN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281-6388
US

IV. Provider business mailing address

250 CORPORATE CENTER CT
STOCKBRIDGE GA
30281-6388
US

V. Phone/Fax

Practice location:
  • Phone: 770-954-8685
  • Fax:
Mailing address:
  • Phone: 770-954-8685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014573
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: