Provider Demographics
NPI:1154673259
Name:CARRERA, PHYLLIS (LPC)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:CARRERA
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 1:1101 COLLIER RD NW
Mailing Address - Street 2:L-5
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318-8231
Mailing Address - Country:US
Mailing Address - Phone:678-360-6018
Mailing Address - Fax:
Practice Address - Street 1:1788-B CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345
Practice Address - Country:US
Practice Address - Phone:678-360-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006957101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional