Provider Demographics
NPI:1174318794
Name:COUNCIL, CEDRIC
Entity type:Individual
Prefix:
First Name:CEDRIC
Middle Name:
Last Name:COUNCIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:866-610-0580
Practice Address - Street 1:4900 IVEY RD NW STE 1626
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4001
Practice Address - Country:US
Practice Address - Phone:470-531-0510
Practice Address - Fax:470-531-0510
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-25-425485106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician