Provider Demographics
NPI:1760711709
Name:CHALK, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CHALK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIBBY
Other - Middle Name:
Other - Last Name:CHALK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4515 GILHAMS RD NE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1905
Mailing Address - Country:US
Mailing Address - Phone:404-932-6651
Mailing Address - Fax:678-952-8134
Practice Address - Street 1:2440 SANDY PLAINS RD
Practice Address - Street 2:BLDG 13 STE 300
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-7217
Practice Address - Country:US
Practice Address - Phone:770-971-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001142106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist