Provider Demographics
NPI:1912576216
Name:FREEMAN, LICIA (MA, MED LMFT)
Entity Type:Individual
Prefix:
First Name:LICIA
Middle Name:
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:MA, MED LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 PIEDMONT RD NE STE 330
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1552
Mailing Address - Country:US
Mailing Address - Phone:770-352-0029
Mailing Address - Fax:
Practice Address - Street 1:3520 PIEDMONT RD NE STE 330
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-1552
Practice Address - Country:US
Practice Address - Phone:770-352-0029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT36758106H00000X
GAMFT000935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist