Provider Demographics
NPI:1679025670
Name:BINGHAM, AUSTEN (LPC)
Entity Type:Individual
Prefix:
First Name:AUSTEN
Middle Name:
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 LONGVIEW ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3709
Mailing Address - Country:US
Mailing Address - Phone:770-639-4520
Mailing Address - Fax:
Practice Address - Street 1:122 LEE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3315
Practice Address - Country:US
Practice Address - Phone:678-664-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009405101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional