Provider Demographics
NPI:1710152483
Name:NOLDY, DANETTE R (MED, LPC)
Entity Type:Individual
Prefix:
First Name:DANETTE
Middle Name:R
Last Name:NOLDY
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 CHURCH ST NE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-8637
Mailing Address - Country:US
Mailing Address - Phone:770-365-0159
Mailing Address - Fax:770-425-8276
Practice Address - Street 1:127 CHURCH ST NE
Practice Address - Street 2:SUITE 350
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8637
Practice Address - Country:US
Practice Address - Phone:770-365-0159
Practice Address - Fax:770-425-8276
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10059908Medicaid