=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164048302
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENESE NATALEE BELL-MARTIN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2020
-----------------------------------------------------
Last Update Date | 06/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5369 LEGACY TRL
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-653-8281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5369 LEGACY TRL
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-5865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-653-8281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC010882
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------