Provider Demographics
NPI:1245795384
Name:ELLIOTT, JAMES SAMPLE JR (LPC, NCC, CRC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:SAMPLE
Last Name:ELLIOTT
Suffix:JR
Gender:M
Credentials:LPC, NCC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 DARBY'S CROSSING DRIVE
Mailing Address - Street 2:SUITE 202 C/O TLCCENTER
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-6008
Mailing Address - Country:US
Mailing Address - Phone:404-850-2020
Mailing Address - Fax:
Practice Address - Street 1:44 DARBY'S CROSSING DRIVE
Practice Address - Street 2:SUITE 202 C/O TLCCENTER
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-6008
Practice Address - Country:US
Practice Address - Phone:404-850-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010314101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
718756OtherNCC
GALPC010314OtherLICENSED PROFESSIONAL COUNSELOR #
26216OtherCERTIFIED REHABILITATION COUNSELOR