Provider Demographics
NPI:1780982249
Name:BRACKETT, O ANITA (LPC006323)
Entity type:Individual
Prefix:MRS
First Name:O
Middle Name:ANITA
Last Name:BRACKETT
Suffix:
Gender:F
Credentials:LPC006323
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 THREE SISTERS TRL
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-7289
Mailing Address - Country:US
Mailing Address - Phone:706-809-8601
Mailing Address - Fax:706-865-5358
Practice Address - Street 1:1419 WASHINGTON ST STE 212
Practice Address - Street 2:
Practice Address - City:CLARKESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30523-5430
Practice Address - Country:US
Practice Address - Phone:706-809-8601
Practice Address - Fax:706-865-5358
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006323101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional