Provider Demographics
NPI:1366847444
Name:DOMOND, ROSELANDE (LPC)
Entity type:Individual
Prefix:
First Name:ROSELANDE
Middle Name:
Last Name:DOMOND
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11658 KADES TRL
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-4012
Mailing Address - Country:US
Mailing Address - Phone:678-886-9112
Mailing Address - Fax:
Practice Address - Street 1:135 BRADFORD SQ STE B
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1902
Practice Address - Country:US
Practice Address - Phone:678-886-9112
Practice Address - Fax:404-900-9088
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007883101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003169295AMedicaid