Provider Demographics
NPI:1134638992
Name:EXPRESSIVE THERAPY INSTITUTE LLC
Entity Type:Organization
Organization Name:EXPRESSIVE THERAPY INSTITUTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHILD & FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANNAI
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ TAVIRA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:770-361-4607
Mailing Address - Street 1:824 WHITEHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6666
Mailing Address - Country:US
Mailing Address - Phone:770-361-4607
Mailing Address - Fax:
Practice Address - Street 1:6015 ATLANTIC BLVD STE A
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1343
Practice Address - Country:US
Practice Address - Phone:770-361-4607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-25
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001573261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)