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NPI Code Detail

MEDICARE: KATRINA SELF LPC

MEDICARE: KATRINA SELF LPC
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
1101YM0800XMental Health CounselorAPC009556GA

General Provider Information

NPI Number : 1538994397
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATRINA SELF LPC
Provider Business Mailing Address
First Line : 104 HARWELL AVE
Second Line :
City : LAGRANGE
State : GA
Zip : 30240-3132
Country : US
Telephone Number : 706-837-0045
Fax Number :
Provider Business Practice Location Address
First Line : 104 HARWELL AVE
Second Line :
City : LAGRANGE
State : GA
Zip : 30240-3132
Country : US
Telephone Number : 706-837-0045
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/03/2024
Last Update Date : 09/03/2024

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Directions to “ KATRINA SELF LPC” Practice Location

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