Healthcare Provider Details

I. General information

NPI: 1063604403
Provider Name (Legal Business Name): JOHN DURY LPC, MFT, MAC, SAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN SWANGO LPC, LMFT, MAC, SAP

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 OLD TUCKER RD
STONE MOUNTAIN GA
30087-3030
US

IV. Provider business mailing address

1180 OLD TUCKER RD
STONE MOUNTAIN GA
30087-3030
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-2800
  • Fax:
Mailing address:
  • Phone: 770-921-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number002917
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number38618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: