=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225148463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHIL E. FOSTER MDIV, LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3104 MERCER UNIVERSITY DR SUITE 220
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-314-8325
-----------------------------------------------------
Fax | 770-457-9480
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3104 MERCER UNIVERSITY DR SUITE 220
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30341-4143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-314-8325
-----------------------------------------------------
Fax | 770-457-9480
-----------------------------------------------------
=====================================================
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 | 1227
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------