Provider Demographics
NPI:1295386423
Name:CALDWELL, BRENTIA J (EDS, LPC)
Entity Type:Individual
Prefix:
First Name:BRENTIA
Middle Name:J
Last Name:CALDWELL
Suffix:
Gender:F
Credentials:EDS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 RIVER SHOALS CV
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-6778
Mailing Address - Country:US
Mailing Address - Phone:404-797-9755
Mailing Address - Fax:
Practice Address - Street 1:3205 RIVER SHOALS CV
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-6778
Practice Address - Country:US
Practice Address - Phone:404-797-9755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-29
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009978101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health