Provider Demographics
NPI:1164243614
Name:GARDNER SPATES, MARCELL DARRELL (LPC)
Entity type:Individual
Prefix:MR
First Name:MARCELL
Middle Name:DARRELL
Last Name:GARDNER SPATES
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3753 OKEFENOKEE RDG
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3382
Mailing Address - Country:US
Mailing Address - Phone:404-514-5802
Mailing Address - Fax:
Practice Address - Street 1:1431 RIVERSIDE PKWY STE A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5996
Practice Address - Country:US
Practice Address - Phone:678-765-9291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC014636101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional