Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | LPC009119 | GA |
NPI | 1003354705 |
---|---|
Provider Name | Bethany Rose Ann Petronella |
First Address | Sandy Springs, GA 30350-2962 |
Second Address | Sandy Springs, GA 30350-2962 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2017 |
Last Update Date | 02/02/2017 |