Provider Demographics
NPI:1619460433
Name:SURI COUNSELING SERVICE, LLC
Entity Type:Organization
Organization Name:SURI COUNSELING SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KAYON
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CCM
Authorized Official - Phone:678-708-3397
Mailing Address - Street 1:168 WALTER WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-6113
Mailing Address - Country:US
Mailing Address - Phone:678-708-3397
Mailing Address - Fax:
Practice Address - Street 1:168 WALTER WAY
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-6113
Practice Address - Country:US
Practice Address - Phone:678-708-3397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0064001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty