Provider Demographics
NPI:1912181082
Name:OHM PSYCOTHERAPY INC
Entity Type:Organization
Organization Name:OHM PSYCOTHERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIC CLINICAL SOCIAL WRKR THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:OPAL
Authorized Official - Middle Name:H
Authorized Official - Last Name:MINOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-375-0479
Mailing Address - Street 1:1083 SIMONTON HILL CT
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045
Mailing Address - Country:US
Mailing Address - Phone:770-375-0479
Mailing Address - Fax:678-985-4228
Practice Address - Street 1:3594 OLD CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341
Practice Address - Country:US
Practice Address - Phone:770-375-0479
Practice Address - Fax:678-985-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0038931041C0700X
NYR04411011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA286447905AMedicaid