Provider Demographics
NPI:1265825566
Name:ATLANTA COUNSELING & DIAGNOTICS CENTER LLC
Entity Type:Organization
Organization Name:ATLANTA COUNSELING & DIAGNOTICS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-676-0589
Mailing Address - Street 1:2090 SUGARLOAF PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-9402
Mailing Address - Country:US
Mailing Address - Phone:770-676-0589
Mailing Address - Fax:
Practice Address - Street 1:2090 SUGARLOAF PKWY STE 115
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-9402
Practice Address - Country:US
Practice Address - Phone:770-658-4833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007754101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003230686AMedicaid
GA003153183BMedicaid