Provider Demographics
NPI:1710937099
Name:COUNSELING & PSYCHIATRY OF GWINNETT, LLC
Entity Type:Organization
Organization Name:COUNSELING & PSYCHIATRY OF GWINNETT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMFT
Authorized Official - Phone:770-978-9393
Mailing Address - Street 1:2301 HENRY CLOWER BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3152
Mailing Address - Country:US
Mailing Address - Phone:770-978-9393
Mailing Address - Fax:770-978-9324
Practice Address - Street 1:2301 HENRY CLOWER BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3152
Practice Address - Country:US
Practice Address - Phone:770-978-9393
Practice Address - Fax:770-978-9324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001166103TC2200X
GACSW031961041C0700X
GA000290106H00000X
GAMFT000665106H00000X
GA0409612084P0800X
GA0455222084P0804X
GA7551363A00000X
GA7753363A00000X
GA7799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP8143Medicare PIN