Provider Demographics
NPI:1306203179
Name:PARKS, EDEN (RN, LPC)
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:
Last Name:PARKS
Suffix:
Gender:F
Credentials:RN, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CRESCENT CHASE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-5729
Mailing Address - Country:US
Mailing Address - Phone:404-399-7480
Mailing Address - Fax:
Practice Address - Street 1:21 CRESCENT CHASE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-5729
Practice Address - Country:US
Practice Address - Phone:404-399-7480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008454101YP2500X
GARN309891163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional