Provider Demographics
NPI:1548876998
Name:PRITCHETT, CONNI COLE (APC)
Entity type:Individual
Prefix:
First Name:CONNI
Middle Name:COLE
Last Name:PRITCHETT
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:JESSICA
Other - Last Name:PRITCHETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APC
Mailing Address - Street 1:5231 GAULEY RIVER DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-2137
Mailing Address - Country:US
Mailing Address - Phone:404-803-8438
Mailing Address - Fax:
Practice Address - Street 1:1030 FAYETTEVILLE RD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30316-2921
Practice Address - Country:US
Practice Address - Phone:404-803-8438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006815101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00000000Medicaid