=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932667300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GAIA COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2019
-----------------------------------------------------
Last Update Date | 03/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 317 W HILL ST STE 205
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30030-4367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-783-2079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2143 WISTERIA WAY NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30317-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOTHERAPIST
-----------------------------------------------------
Name | CHRISTY BURKETT
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 404-783-2079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------