=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386994275
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY COUNSELING ATLANTA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 09/18/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 CHURCH ST SUITE 109
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-822-3954
-----------------------------------------------------
Fax | 770-452-0046
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 215 CHURCH ST SUITE 109
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-3330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-822-3954
-----------------------------------------------------
Fax | 770-452-0046
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MARRIAGE AND FAMILY THERAPIST
-----------------------------------------------------
Name | MARY ELIZABETH TOLER
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 404-822-3954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 001112
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------