Healthcare Provider Details

I. General information

NPI: 1023298908
Provider Name (Legal Business Name): ALVIN C SUTHERLAND LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 SHAWNEE INDIAN LN
SUWANEE GA
30024-6531
US

IV. Provider business mailing address

4200 RESERVE HILL XING
DOUGLASVILLE GA
30135-5188
US

V. Phone/Fax

Practice location:
  • Phone: 337-319-5476
  • Fax:
Mailing address:
  • Phone: 770-853-6372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: