Provider Demographics
NPI:1083249148
Name:RAY, AMANDA FAYE (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:FAYE
Last Name:RAY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 CARLTON PL NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3623
Mailing Address - Country:US
Mailing Address - Phone:229-563-4381
Mailing Address - Fax:
Practice Address - Street 1:11675 CENTURY DR STE B&C
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-8366
Practice Address - Country:US
Practice Address - Phone:678-740-3990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010909101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health