Provider Demographics
NPI:1952859829
Name:CREATING A DIFFERENCE
Entity Type:Organization
Organization Name:CREATING A DIFFERENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SIR ALLEN
Authorized Official - Middle Name:DUPREE
Authorized Official - Last Name:PEGUES
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, NCC
Authorized Official - Phone:770-882-5895
Mailing Address - Street 1:413 ARBOR CIR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8603
Mailing Address - Country:US
Mailing Address - Phone:770-882-5895
Mailing Address - Fax:
Practice Address - Street 1:1333 MOUNT ZION RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2357
Practice Address - Country:US
Practice Address - Phone:770-882-5895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008654251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health