Provider Demographics
NPI:1114677705
Name:GOUNTENI, GAELLE LAURE ESSENAM (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:GAELLE LAURE
Middle Name:ESSENAM
Last Name:GOUNTENI
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-0726
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4125 ATLANTA RD SE STE 120
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6521
Practice Address - Country:US
Practice Address - Phone:770-858-5377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN2703652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN270365OtherLICENSE NUMBER