Provider Demographics
NPI:1780817387
Name:CECCOLI, THEODORE H (LPC)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:H
Last Name:CECCOLI
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8014 LONGLEAF DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-8666
Mailing Address - Country:US
Mailing Address - Phone:770-838-9806
Mailing Address - Fax:770-834-9188
Practice Address - Street 1:415 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3921
Practice Address - Country:US
Practice Address - Phone:770-838-9806
Practice Address - Fax:770-834-9188
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-29
Last Update Date:2009-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC005686101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional