Provider Demographics
NPI:1881704344
Name:FRESH, EDITH (PHD)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:FRESH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 PIEDMONT AVE
Mailing Address - Street 2:STE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303
Mailing Address - Country:US
Mailing Address - Phone:404-756-1400
Mailing Address - Fax:404-756-1400
Practice Address - Street 1:1513 EAST CLEVELAND AVE BLGD 500
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-6903
Practice Address - Country:US
Practice Address - Phone:404-752-1000
Practice Address - Fax:404-752-1191
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PSY1863103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00612763AMedicaid
GA00612763AMedicaid