1477044311 NPI number — CAMILLE ANTOINETT COLSON LPC, CRC

Table of content: CAMILLE ANTOINETT COLSON LPC, CRC (NPI 1477044311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477044311 NPI number — CAMILLE ANTOINETT COLSON LPC, CRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLSON
Provider First Name:
CAMILLE
Provider Middle Name:
ANTOINETT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, CRC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477044311
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2890 GEORGIA HIGHWAY 212 SW STE A-319
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONYERS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30094-3363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-610-0343
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3774 LAVISTA RD STE 100B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCKER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30084-5618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-909-4100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  009941 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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