=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609313113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S.T.A.R. COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2017
-----------------------------------------------------
Last Update Date | 01/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5960 CROOKED CREEK RD
-----------------------------------------------------
City | PEACHTREE CORNERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-6219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-664-4517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2765 HIDDEN CREEK DR
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052-7595
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-664-4517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | OTIS CHANDLER
-----------------------------------------------------
Credential | BSW, LCSW
-----------------------------------------------------
Telephone | 404-664-4517
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW005989
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------