Provider Demographics
NPI:1336466408
Name:ABERNATHY, CARL
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:ABERNATHY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 S COBB DR SE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6303
Mailing Address - Country:US
Mailing Address - Phone:770-862-7585
Mailing Address - Fax:770-435-4088
Practice Address - Street 1:4015 S COBB DR SE
Practice Address - Street 2:SUITE 140
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6303
Practice Address - Country:US
Practice Address - Phone:770-862-7585
Practice Address - Fax:770-435-4088
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC003955101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional