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General NPI Number Information
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NPI Number | 1922036508
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Entity Type | Organization
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Legal Business Name | PROMEDICA, INC.
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 04/28/2008
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Provider Practice Location Address
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Address Line | 2430 TUCKER DR BLDG A
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City | LOGANVILLE
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State | GA
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Zip | 30052-4390
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Country | US
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Telephone | 770-554-8812
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Fax | 770-554-9810
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Provider Business Mailing Address
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Address Line | 2430 TUCKER DR BLDG A
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City | LOGANVILLE
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State | GA
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Zip | 30052-4390
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Country | US
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Telephone | 770-554-8812
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Fax | 770-554-9810
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Authorized Official
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Title or Position | PRESIDENT & CEO
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Name | MS. KIMBERLY H. LITTRELL
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Credential | MS, APRN, BC
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Telephone | 770-554-8812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 029689
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License Number State | GA
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