Provider Demographics
NPI:1710218805
Name:ISSENMANN, ANTHONY (PHD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:ISSENMANN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 FILE ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-3023
Mailing Address - Country:US
Mailing Address - Phone:706-212-2037
Mailing Address - Fax:706-212-0354
Practice Address - Street 1:236 FILE STREET
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525
Practice Address - Country:US
Practice Address - Phone:706-212-2037
Practice Address - Fax:706-212-0354
Is Sole Proprietor?:No
Enumeration Date:2010-01-29
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001125106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist