Provider Demographics
NPI:1376182527
Name:AMOS, COLISHA MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:COLISHA
Middle Name:MARIE
Last Name:AMOS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WASHINGTON RD STE 107 BOX 261
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2355
Mailing Address - Country:US
Mailing Address - Phone:706-691-9688
Mailing Address - Fax:
Practice Address - Street 1:3345 SADDLEBROOK DR
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815
Practice Address - Country:US
Practice Address - Phone:706-691-9688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010193101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health