Healthcare Provider Details

I. General information

NPI: 1780125948
Provider Name (Legal Business Name): GWINNETT COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 03/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3465 LAWRENCEVILLE SUWANEE RD SUITE A
SUWANEE GA
30024-7465
US

IV. Provider business mailing address

3465 LAWRENCEVILLE SUWANEE RD SUITE A
SUWANEE GA
30024-7465
US

V. Phone/Fax

Practice location:
  • Phone: 678-926-9859
  • Fax:
Mailing address:
  • Phone: 678-926-9859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009289
License Number StateGA

VIII. Authorized Official

Name: LORIEN MAGNUS
Title or Position: CO-OWNER
Credential:
Phone: 678-926-9859