Provider Demographics
NPI:1891019212
Name:LIFEGATE COUNSELING CENTER @ PEACHTREE, INC.
Entity Type:Organization
Organization Name:LIFEGATE COUNSELING CENTER @ PEACHTREE, INC.
Other - Org Name:PEACHTREE COUNSELING CENTER, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATIVE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:P
Authorized Official - Last Name:RODES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-842-3150
Mailing Address - Street 1:3434 ROSWELL RD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1202
Mailing Address - Country:US
Mailing Address - Phone:404-842-3150
Mailing Address - Fax:404-842-3162
Practice Address - Street 1:3434 ROSWELL RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1202
Practice Address - Country:US
Practice Address - Phone:404-842-3150
Practice Address - Fax:404-842-3162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2010-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty