=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043038656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREA LINN FERENCHIK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 TRIBBLE GAP RD STE B
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30040-2475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-615-8285
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4115 HEDGEMOORE CT
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-9454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-852-3807
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 009787
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------