Provider Demographics
NPI:1366454100
Name:GITTELSON, MOSHE MARVIN E (LCSW)
Entity Type:Individual
Prefix:
First Name:MOSHE MARVIN
Middle Name:E
Last Name:GITTELSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 ROBIN HOOD RD NE
Mailing Address - Street 2:NORTHEAST
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2635
Mailing Address - Country:US
Mailing Address - Phone:404-617-2469
Mailing Address - Fax:770-603-3063
Practice Address - Street 1:250 ARROWHEAD BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1106
Practice Address - Country:US
Practice Address - Phone:404-617-2469
Practice Address - Fax:770-603-3063
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0010611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical