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General NPI Number Information
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NPI Number | 1811503402
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Entity Type | Individual
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Provider Name | TRACY CULLOM MA, LAPC
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Gender | Female
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Dates
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Enumeration Date | 09/18/2020
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Last Update Date | 09/18/2020
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Provider Practice Location Address
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Address Line | 4411 SUWANEE DAM RD
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City | SUWANEE
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State | GA
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Zip | 30024-8701
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Country | US
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Telephone | 678-993-8464
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Fax |
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Provider Business Mailing Address
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Address Line | 180 PIONEER DR
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City | ATHENS
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State | GA
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Zip | 30605-4016
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Country | US
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Telephone | 404-259-8465
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | APC007578
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License Number State | GA
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