Provider Demographics
NPI:1609343789
Name:GAINES, SYDNEY NICOLE
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:NICOLE
Last Name:GAINES
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 1:1803 CHASELAKE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-7713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2636 MLK JR DR SW STE 12AND24
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1634
Practice Address - Country:US
Practice Address - Phone:678-705-3828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-26
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist