Provider Demographics
NPI:1508344581
Name:SOUTH RIVER COUNSELING & CONSULTING, LLC
Entity Type:Organization
Organization Name:SOUTH RIVER COUNSELING & CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:FRANCES
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:OLDHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:770-337-8591
Mailing Address - Street 1:1430 STARCREST DR NE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3830
Mailing Address - Country:US
Mailing Address - Phone:470-252-8270
Mailing Address - Fax:470-252-8270
Practice Address - Street 1:1430 STARCREST DR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3830
Practice Address - Country:US
Practice Address - Phone:470-252-8270
Practice Address - Fax:470-252-8270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007661101YP2500X
GACSW0020861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty