Provider Demographics
NPI:1598216061
Name:MARIETTA COUNSELING
Entity type:Organization
Organization Name:MARIETTA COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MFT
Authorized Official - Phone:678-677-7484
Mailing Address - Street 1:2440 SANDY PLAINS RD
Mailing Address - Street 2:BLDG #25
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-7217
Mailing Address - Country:US
Mailing Address - Phone:770-971-9311
Mailing Address - Fax:
Practice Address - Street 1:2440 SANDY PLAINS RD
Practice Address - Street 2:BLDG #25
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-7217
Practice Address - Country:US
Practice Address - Phone:770-971-9311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANOT ISSUED YET261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health