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General NPI Number Information
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NPI Number | 1609916147
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Entity Type | Organization
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Legal Business Name | FAMILY ART THERAPY CENTER PC
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Dates
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Enumeration Date | 02/07/2007
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Last Update Date | 03/13/2023
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Provider Practice Location Address
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Address Line | 109 OLD LIVERY STREET
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City | CLAYTON
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State | GA
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Zip | 30525
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Country | US
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Telephone | 706-782-0717
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Fax | 706-782-5266
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Provider Business Mailing Address
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Address Line | PO BOX 1689
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City | CLAYTON
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State | GA
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Zip | 30525-0043
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Country | US
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Telephone | 706-782-0717
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Fax | 706-782-5266
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Authorized Official
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Title or Position | CEO
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Name | MS. CHRISTY ELIZABETH BLACK
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Credential | LPC, ATR-BC
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Telephone | 64-903-5357
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC 003219
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License Number State | GA
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