Provider Demographics
NPI:1184303372
Name:NALLS, ANGELIA PORTIA (M DIV, MFT)
Entity type:Individual
Prefix:
First Name:ANGELIA
Middle Name:PORTIA
Last Name:NALLS
Suffix:
Gender:F
Credentials:M DIV, MFT
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:NALLS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 951
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:GA
Mailing Address - Zip Code:30272-0951
Mailing Address - Country:US
Mailing Address - Phone:404-218-8524
Mailing Address - Fax:
Practice Address - Street 1:3940 SOMERLED TRL
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-2036
Practice Address - Country:US
Practice Address - Phone:404-218-8524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAMFT000713106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist