1639754674 NPI number — MS. CAROLYN CETO- KOUMANDARAKIS LCSW

Table of content: MS. CAROLYN CETO- KOUMANDARAKIS LCSW (NPI 1639754674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639754674 NPI number — MS. CAROLYN CETO- KOUMANDARAKIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CETO- KOUMANDARAKIS
Provider First Name:
CAROLYN
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1639754674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4439 N ELIZABETH LN SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-5321
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-938-2422
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
315 W PONCE DE LEON AVE STE 370
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30030-2476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-938-2422
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2021

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: 1041C0700X , with the licence number:  CSW007019 , 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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