Provider Demographics
NPI:1407289721
Name:SOURCE OF STRENGTH PROFESSIONAL COUNSELING, PC
Entity Type:Organization
Organization Name:SOURCE OF STRENGTH PROFESSIONAL COUNSELING, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:404-272-3436
Mailing Address - Street 1:2890 HIGHWAY 212 SW
Mailing Address - Street 2:SUITE A-289
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3363
Mailing Address - Country:US
Mailing Address - Phone:404-272-3436
Mailing Address - Fax:404-855-2887
Practice Address - Street 1:821 PAVILION CT
Practice Address - Street 2:SUITE A
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5222
Practice Address - Country:US
Practice Address - Phone:404-272-3436
Practice Address - Fax:404-855-2887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-11
Last Update Date:2013-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006099251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133448AMedicaid
GA003133452AMedicaid