1164243614 NPI number — MR. MARCELL DARRELL GARDNER SPATES LPC

Table of content: MR. MARCELL DARRELL GARDNER SPATES LPC (NPI 1164243614)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164243614 NPI number — MR. MARCELL DARRELL GARDNER SPATES LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER SPATES
Provider First Name:
MARCELL
Provider Middle Name:
DARRELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
M

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:
1164243614
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3753 OKEFENOKEE RDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30052-3382
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-514-5802
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1431 RIVERSIDE PKWY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30043-5996
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-765-9291
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2024

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:  LPC014636 , 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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