Provider Demographics
NPI:1114550282
Name:FODDRELL, WINTER CHARNAE (MA, LPC, NCC)
Entity type:Individual
Prefix:
First Name:WINTER
Middle Name:CHARNAE
Last Name:FODDRELL
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 ROCK MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-1507
Mailing Address - Country:US
Mailing Address - Phone:336-280-5964
Mailing Address - Fax:
Practice Address - Street 1:1244 CLAIRMONT RD STE 204
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1263
Practice Address - Country:US
Practice Address - Phone:470-205-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011302101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health