Provider Demographics
NPI:1063751014
Name:CHANTAY GOLSON
Entity type:Organization
Organization Name:CHANTAY GOLSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANTAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CAMS
Authorized Official - Phone:770-280-7288
Mailing Address - Street 1:242 FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-3804
Mailing Address - Country:US
Mailing Address - Phone:770-280-7288
Mailing Address - Fax:770-983-6098
Practice Address - Street 1:340 BOULEVARD NE
Practice Address - Street 2:SUITE 611
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-1273
Practice Address - Country:US
Practice Address - Phone:770-280-7288
Practice Address - Fax:770-983-6098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003126621AMedicaid