Provider Demographics
NPI:1316216104
Name:HOUSTON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:HOUSTON
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 1:253 VILLA GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-7110
Mailing Address - Country:US
Mailing Address - Phone:678-668-3407
Mailing Address - Fax:678-609-1612
Practice Address - Street 1:3781 PRESIDENTIAL PKWY
Practice Address - Street 2:111D
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30340-3702
Practice Address - Country:US
Practice Address - Phone:678-668-3407
Practice Address - Fax:770-452-1509
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC5948101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA536207921AMedicaid