Provider Demographics
NPI:1639754674
Name:CETO- KOUMANDARAKIS, CAROLYN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:
Last Name:CETO- KOUMANDARAKIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4439 N ELIZABETH LN SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5321
Mailing Address - Country:US
Mailing Address - Phone:678-938-2422
Mailing Address - Fax:
Practice Address - Street 1:315 W PONCE DE LEON AVE STE 370
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2476
Practice Address - Country:US
Practice Address - Phone:678-938-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0070191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical