=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861739831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEBORAH PRUDDEN LATHROP LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2013
-----------------------------------------------------
Last Update Date | 05/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5881 GLENRIDGE DR STE 240
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-777-5036
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5881 GLENRIDGE DR STE 240
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-777-5036
-----------------------------------------------------
Fax | 770-346-0488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | MSW005159
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | CSW006772
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------