Basic Information
| Provider Information | |||||||||
| NPI: | 1710937099 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNSELING & PSYCHIATRY OF GWINNETT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 HENRY CLOWER BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300783152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
| FaxNumber: | 7709789324 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HENRY CLOWER BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300783152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
| FaxNumber: | 7709789324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 03/23/2016 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7709789393 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, LMFT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 045522 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 106H00000X | 000290 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | MFT000665 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 103TC2200X | 001166 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 1041C0700X | CSW03196 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363A00000X | 7799 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 7551 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 7753 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2084P0800X | 040961 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.