Provider Demographics
NPI:1467102582
Name:AGHA, HIBBAH AILYA
Entity Type:Individual
Prefix:
First Name:HIBBAH
Middle Name:AILYA
Last Name:AGHA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 CHINOOK CT SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-7437
Mailing Address - Country:US
Mailing Address - Phone:678-735-8153
Mailing Address - Fax:
Practice Address - Street 1:5400 LAUREL SPRINGS PKWY STE 802
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6096
Practice Address - Country:US
Practice Address - Phone:404-808-1161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty