=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952253825
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR VICTIMS OF TORTURE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2026
-----------------------------------------------------
Last Update Date | 02/12/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4020 E PONCE DE LEON AVE
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-545-2776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4020 E PONCE DE LEON AVE
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30021-1815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-545-2776
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | KA THAO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-436-4860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------