Provider Demographics
NPI:1740634351
Name:COUSAR-ROPER, GREGORY DAQUAN I (JUNIOR COUNSELOR,CAS)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:DAQUAN
Last Name:COUSAR-ROPER
Suffix:I
Gender:M
Credentials:JUNIOR COUNSELOR,CAS
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6482 KLINECT CT
Mailing Address - Street 2:B
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-7111
Mailing Address - Country:US
Mailing Address - Phone:678-558-7078
Mailing Address - Fax:
Practice Address - Street 1:6482 KLINECT CT
Practice Address - Street 2:B
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-7111
Practice Address - Country:US
Practice Address - Phone:678-558-7078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAEN799987101Y00000X
GAT0086101YA0400X
GA1535049078861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical