Provider Demographics
NPI:1083153142
Name:YOUNG-GIBRALTARIK, CONNIE J (MED, MA, LPC)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:J
Last Name:YOUNG-GIBRALTARIK
Suffix:
Gender:F
Credentials:MED, MA, LPC
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Mailing Address - Street 1:950 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 665
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:510-914-7540
Mailing Address - Fax:770-629-2139
Practice Address - Street 1:950 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 665
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7343
Practice Address - Country:US
Practice Address - Phone:510-914-7540
Practice Address - Fax:770-629-2139
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GALPC009420101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional