Provider Demographics
NPI:1073892923
Name:CHEROKEE CENTER FOR CHANGE COUNSELING, INC.
Entity Type:Organization
Organization Name:CHEROKEE CENTER FOR CHANGE COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ITA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:770-928-7300
Mailing Address - Street 1:409 OLD BORING LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-2495
Mailing Address - Country:US
Mailing Address - Phone:770-928-7300
Mailing Address - Fax:770-928-7558
Practice Address - Street 1:409 OLD BORING LANE
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-2495
Practice Address - Country:US
Practice Address - Phone:770-928-7300
Practice Address - Fax:770-928-7558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2347101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty