Provider Demographics
NPI:1225288111
Name:GRESHAM, ANGELA (MA)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:GRESHAM
Suffix:
Gender:F
Credentials:MA
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 3081
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30031-3081
Mailing Address - Country:US
Mailing Address - Phone:770-374-9056
Mailing Address - Fax:404-377-2782
Practice Address - Street 1:2531 BRIARCLIFF RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3017
Practice Address - Country:US
Practice Address - Phone:770-905-2898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9077369101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor