Provider Demographics
NPI:1477068617
Name:THAXTON, RICHARD JOHN III (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JOHN
Last Name:THAXTON
Suffix:III
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:959 FAIRLONG DR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-7894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3459 ACWORTH DUE WEST RD NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5819
Practice Address - Country:US
Practice Address - Phone:678-587-8858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-11
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011689101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health