Provider Demographics
NPI:1376523852
Name:FESPERMAN, GEORGIA LAVERNE (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:GEORGIA
Middle Name:LAVERNE
Last Name:FESPERMAN
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15206 WATERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-3250
Mailing Address - Country:US
Mailing Address - Phone:704-947-7497
Mailing Address - Fax:
Practice Address - Street 1:9835 NORTHCROSS CENTER CT
Practice Address - Street 2:SUITE B
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7346
Practice Address - Country:US
Practice Address - Phone:704-896-8688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0026561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106176Medicaid