Provider Demographics
NPI:1184233363
Name:HEDDEN, LISA (APC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HEDDEN
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3754 LAVISTA RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5627
Mailing Address - Country:US
Mailing Address - Phone:404-994-1034
Mailing Address - Fax:
Practice Address - Street 1:3754 LAVISTA RD STE 200
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5627
Practice Address - Country:US
Practice Address - Phone:404-994-1034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC06597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional