Provider Demographics
NPI:1427650258
Name:FODROCZI, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:FODROCZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 WADE GREEN RD NW STE 414
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1763
Mailing Address - Country:US
Mailing Address - Phone:678-213-2194
Mailing Address - Fax:678-922-7767
Practice Address - Street 1:1000 JOHNSON FERRY RD STE 123
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-2114
Practice Address - Country:US
Practice Address - Phone:678-213-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011366101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional