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General NPI Number Information
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NPI Number | 1215358015
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Entity Type | Organization
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Legal Business Name | LIVING FULLY PSYCHOTHERAPY AND CONSULTING, LLC
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Dates
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Enumeration Date | 12/20/2013
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Last Update Date | 12/20/2013
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Provider Practice Location Address
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Address Line | 1463 OXFORD RD NE
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City | ATLANTA
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State | GA
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Zip | 30322-1046
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Country | US
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Telephone | 678-591-9117
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Fax |
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Provider Business Mailing Address
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Address Line | 553 COBBLESTONE TRL
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City | AVONDALE ESTATES
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State | GA
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Zip | 30002-1211
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Country | US
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Telephone | 678-591-9117
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Fax |
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Authorized Official
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Title or Position | OWNER/DIRECTOR
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Name | DR. PEGAH MOGHADDAM
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Credential | PSY.D.
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Telephone | 678-591-9117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | PSY003405
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License Number State | GA
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