Provider Demographics
NPI:1629503248
Name:FIELDS, LARRY MICHAEL (MS, LPC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:MICHAEL
Last Name:FIELDS
Suffix:
Gender:M
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 WHITE OAK LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-5510
Mailing Address - Country:US
Mailing Address - Phone:770-842-5083
Mailing Address - Fax:208-439-9293
Practice Address - Street 1:2801 WHITE OAK LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-5510
Practice Address - Country:US
Practice Address - Phone:770-842-5083
Practice Address - Fax:208-439-9293
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007196101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional