Provider Demographics
NPI:1134674104
Name:BOSTICK, RITA THETFORD (MA, LPC)
Entity type:Individual
Prefix:
First Name:RITA
Middle Name:THETFORD
Last Name:BOSTICK
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 PONCE DE LEON AVE NE
Mailing Address - Street 2:SUITE #6
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4252
Mailing Address - Country:US
Mailing Address - Phone:404-304-2131
Mailing Address - Fax:
Practice Address - Street 1:881 PONCE DE LEON AVE NE
Practice Address - Street 2:SUITE #6
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4252
Practice Address - Country:US
Practice Address - Phone:404-304-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004411101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional