Provider Demographics
NPI:1427715085
Name:KOTH, KRISTEN HEATHER (LPC)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:HEATHER
Last Name:KOTH
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 1:3044 BRIARCLIFF RD NE APT 7
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2619
Mailing Address - Country:US
Mailing Address - Phone:404-805-9755
Mailing Address - Fax:
Practice Address - Street 1:3754 LAVISTA RD STE 200
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5627
Practice Address - Country:US
Practice Address - Phone:470-344-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011784101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health