Provider Demographics
NPI:1922580448
Name:THE INTIMACY CENTER OF GEORGIA
Entity Type:Organization
Organization Name:THE INTIMACY CENTER OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTHOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-750-3952
Mailing Address - Street 1:3400 CHAPEL HILL RD STE 317
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1739
Mailing Address - Country:US
Mailing Address - Phone:678-750-3952
Mailing Address - Fax:678-838-4595
Practice Address - Street 1:3400 CHAPEL HILL RD STE 317
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1739
Practice Address - Country:US
Practice Address - Phone:678-750-3952
Practice Address - Fax:678-838-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-31
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001585106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty