Provider Demographics
NPI:1659650331
Name:KIRK, ALAN B (PHD, LCSW)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:B
Last Name:KIRK
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 ROBERTA DR SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30008-3855
Mailing Address - Country:US
Mailing Address - Phone:770-419-3120
Mailing Address - Fax:770-419-3121
Practice Address - Street 1:1605 ROBERTA DR SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30008-3855
Practice Address - Country:US
Practice Address - Phone:770-419-3120
Practice Address - Fax:770-419-3121
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0034351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW003435OtherLCSW LICENSE #