Provider Demographics
NPI:1760933287
Name:RECONNECT THERAPEUTIC ASSOCIATES LLC.
Entity Type:Organization
Organization Name:RECONNECT THERAPEUTIC ASSOCIATES LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RONAY
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-424-8650
Mailing Address - Street 1:1264 CONCORD RD SE STE 106
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-5302
Mailing Address - Country:US
Mailing Address - Phone:678-424-8650
Mailing Address - Fax:678-424-8653
Practice Address - Street 1:1264 CONCORD RD SE
Practice Address - Street 2:SE SUITE 106
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-5302
Practice Address - Country:US
Practice Address - Phone:678-424-8650
Practice Address - Fax:678-424-8653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007466101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003153870AMedicaid