Provider Demographics
NPI:1790197804
Name:COUNSELING SERVICES OF LAGRANGE, INC.
Entity Type:Organization
Organization Name:COUNSELING SERVICES OF LAGRANGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:DUNLAP
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-884-5050
Mailing Address - Street 1:610 RIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2236
Mailing Address - Country:US
Mailing Address - Phone:706-884-5050
Mailing Address - Fax:706-884-5056
Practice Address - Street 1:610 RIDLEY AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2236
Practice Address - Country:US
Practice Address - Phone:706-884-5050
Practice Address - Fax:706-884-5056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003497103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty