Provider Demographics
NPI:1376150870
Name:SOUTHEAST PERINATAL COUNSELING LLC
Entity Type:Organization
Organization Name:SOUTHEAST PERINATAL COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-404-9886
Mailing Address - Street 1:388 BULLSBORO DR # 301
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-1069
Mailing Address - Country:US
Mailing Address - Phone:678-404-9886
Mailing Address - Fax:
Practice Address - Street 1:1450 NEWNAN CROSSING BLVD E APT 4213
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-0010
Practice Address - Country:US
Practice Address - Phone:678-404-9886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty