Provider Demographics
NPI:1700321320
Name:MANRADGH, RAJEIVE ANTWAN (LAPC, NCC)
Entity Type:Individual
Prefix:
First Name:RAJEIVE
Middle Name:ANTWAN
Last Name:MANRADGH
Suffix:
Gender:M
Credentials:LAPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 WHITE ROSE CT
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8644
Mailing Address - Country:US
Mailing Address - Phone:678-697-4153
Mailing Address - Fax:
Practice Address - Street 1:109 WHITE ROSE CT
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8644
Practice Address - Country:US
Practice Address - Phone:678-697-4153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC005768101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health