Provider Demographics
NPI:1215358015
Name:LIVING FULLY PSYCHOTHERAPY AND CONSULTING, LLC
Entity Type:Organization
Organization Name:LIVING FULLY PSYCHOTHERAPY AND CONSULTING, LLC
Other - Org Name:LIVING FULLY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PEGAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGHADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:678-591-9117
Mailing Address - Street 1:553 COBBLESTONE TRL
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-1211
Mailing Address - Country:US
Mailing Address - Phone:678-591-9117
Mailing Address - Fax:
Practice Address - Street 1:1463 OXFORD RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-1046
Practice Address - Country:US
Practice Address - Phone:678-591-9117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003405261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)