Provider Demographics
NPI:1629309083
Name:GRISSOM, CAUDIE R (LPC)
Entity Type:Individual
Prefix:
First Name:CAUDIE
Middle Name:R
Last Name:GRISSOM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2616 OLD WESLEY CHAPEL RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-2367
Mailing Address - Country:US
Mailing Address - Phone:404-408-1253
Mailing Address - Fax:404-289-8055
Practice Address - Street 1:2616 OLD WESLEY CHAPEL RD
Practice Address - Street 2:SUITE 207
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-2367
Practice Address - Country:US
Practice Address - Phone:404-408-1253
Practice Address - Fax:404-289-8055
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010853725101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health