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General NPI Number Information
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NPI Number | 1376150870
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Entity Type | Organization
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Legal Business Name | SOUTHEAST PERINATAL COUNSELING LLC
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Dates
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Enumeration Date | 09/28/2020
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Last Update Date | 09/28/2020
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Provider Practice Location Address
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Address Line | 1450 NEWNAN CROSSING BLVD E APT 4213
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City | NEWNAN
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State | GA
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Zip | 30265-0010
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Country | US
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Telephone | 678-404-9886
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Fax |
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Provider Business Mailing Address
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Address Line | 388 BULLSBORO DR # 301
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City | NEWNAN
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State | GA
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Zip | 30263-1069
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Country | US
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Telephone | 678-404-9886
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | CRYSTAL WILSON
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Credential | LCSW
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Telephone | 678-404-9886
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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