1710279971 NPI number — MS. ZELLA MAE UPSHAW LPC

Table of content: MS. ZELLA MAE UPSHAW LPC (NPI 1710279971)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710279971 NPI number — MS. ZELLA MAE UPSHAW LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UPSHAW
Provider First Name:
ZELLA
Provider Middle Name:
MAE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1710279971
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
347 AMBERIDGE DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTERSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30121-7344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-384-5482
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 N TENNESSEE ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
CARTERSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30120-8514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-384-5482
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2011

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: 101YM0800X , with the licence number:  LPC005262 , 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)

  • Identifier: 003111483A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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