Provider Demographics
NPI:1326734252
Name:BAIR, THEODORA LONGARDT (MED, MS, NCC)
Entity Type:Individual
Prefix:MRS
First Name:THEODORA
Middle Name:LONGARDT
Last Name:BAIR
Suffix:
Gender:F
Credentials:MED, MS, NCC
Other - Prefix:
Other - First Name:TEDDI
Other - Middle Name:
Other - Last Name:BAIR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, MS, NCC
Mailing Address - Street 1:2744 PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2937
Mailing Address - Country:US
Mailing Address - Phone:404-333-8760
Mailing Address - Fax:
Practice Address - Street 1:2744 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2937
Practice Address - Country:US
Practice Address - Phone:404-333-8760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008713101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health