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General NPI Number Information
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NPI Number | 1922580448
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Entity Type | Organization
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Legal Business Name | THE INTIMACY CENTER OF GEORGIA
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Dates
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Enumeration Date | 08/31/2018
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Last Update Date | 06/28/2021
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Provider Practice Location Address
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Address Line | 3400 CHAPEL HILL RD STE 317
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-1739
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Country | US
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Telephone | 678-750-3952
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Fax | 678-838-4595
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Provider Business Mailing Address
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Address Line | 3400 CHAPEL HILL RD STE 317
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City | DOUGLASVILLE
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State | GA
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Zip | 30135-1739
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Country | US
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Telephone | 678-750-3952
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Fax | 678-838-4595
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | STEPHANIE WALTHOUR
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Credential |
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Telephone | 678-750-3952
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFT001585
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License Number State | GA
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