=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871957670
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLAGE COMMUNITY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2016
-----------------------------------------------------
Last Update Date | 04/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 S PERRY ST
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-933-9006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 S PERRY ST
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-4840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-933-9006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CARMAN SUZANNE CLARK
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 678-933-9006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC004465
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------