Provider Demographics
NPI:1457911067
Name:NALLS, SYREETA RENEE (LPC)
Entity Type:Individual
Prefix:
First Name:SYREETA
Middle Name:RENEE
Last Name:NALLS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 QUARTZ DR STE 103A
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3201
Mailing Address - Country:US
Mailing Address - Phone:770-812-3541
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 103A
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3201
Practice Address - Country:US
Practice Address - Phone:770-812-3541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006218101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional