Provider Demographics
NPI:1346790433
Name:GAINES, DENITRA L (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:DENITRA
Middle Name:L
Last Name:GAINES
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3114 CHEROKEE ST NW
Mailing Address - Street 2:SUITE 209
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6524
Mailing Address - Country:US
Mailing Address - Phone:770-627-3550
Mailing Address - Fax:678-401-8928
Practice Address - Street 1:3114 CHEROKEE ST NW
Practice Address - Street 2:SUITE 209
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6524
Practice Address - Country:US
Practice Address - Phone:770-627-3550
Practice Address - Fax:678-401-8928
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009169101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional