Provider Demographics
NPI:1982213716
Name:CENTERSIDE COUNSELING & CONSULTING LLC
Entity Type:Organization
Organization Name:CENTERSIDE COUNSELING & CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WISEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-365-3695
Mailing Address - Street 1:1755 N BROWN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-2018
Mailing Address - Country:US
Mailing Address - Phone:678-365-3695
Mailing Address - Fax:
Practice Address - Street 1:1755 N BROWN RD STE 200
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-2018
Practice Address - Country:US
Practice Address - Phone:678-365-3695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty