Healthcare Provider Details

I. General information

NPI: 1992060982
Provider Name (Legal Business Name): MADELINE DIANE CHRESTMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 TENCH RD STE 1220
SUWANEE GA
30024-6742
US

IV. Provider business mailing address

4485 TENCH RD STE 1220
SUWANEE GA
30024-6742
US

V. Phone/Fax

Practice location:
  • Phone: 770-378-6835
  • Fax:
Mailing address:
  • Phone: 770-378-6835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCSW004747
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW004739
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004747
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: