Provider Demographics
NPI:1609902543
Name:KRESGE, ELIZABETH MADDOX
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MADDOX
Last Name:KRESGE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:MADDOX
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:4580 MYRTLE HILL RD NE
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1521
Mailing Address - Country:US
Mailing Address - Phone:404-944-9431
Mailing Address - Fax:770-429-1746
Practice Address - Street 1:3745 CHEROKEE ST NW
Practice Address - Street 2:SUITE 202
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6733
Practice Address - Country:US
Practice Address - Phone:404-944-9431
Practice Address - Fax:770-429-1746
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC 001514101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional