Provider Demographics
NPI:1790037745
Name:JEANLOUIS, MARIE CARMELLE (MBA, BCCC)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CARMELLE
Last Name:JEANLOUIS
Suffix:
Gender:F
Credentials:MBA, BCCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 RUSSETT CT SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-4644
Mailing Address - Country:US
Mailing Address - Phone:770-895-5522
Mailing Address - Fax:
Practice Address - Street 1:538 RUSSETT CT SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-4644
Practice Address - Country:US
Practice Address - Phone:770-895-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA09122676101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA09122676Medicaid