MEDICARE: PARISA NICOLE POORAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1528527975
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PARISA NICOLE POORAK

Provider Business Mailing Address
First Line	:	15000 PARKVIEW LN APT 6205
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30005-5428
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2450 ATLANTA HWY STE 1503
Second Line	:
City	:	CUMMING
State	:	GA
Zip	:	30040-1277
Country	:	US
Telephone Number	:	678-772-1031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/15/2019
Last Update Date	:	03/15/2019

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