Provider Demographics
NPI:1780880690
Name:DERENTHAL, ANNALISA (MS, LPC, NCC)
Entity type:Individual
Prefix:MRS
First Name:ANNALISA
Middle Name:
Last Name:DERENTHAL
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:MRS
Other - First Name:ANNA
Other - Middle Name:LISA
Other - Last Name:DERENTHAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, LPC, NCC
Mailing Address - Street 1:530 JON SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-2125
Mailing Address - Country:US
Mailing Address - Phone:678-431-3901
Mailing Address - Fax:
Practice Address - Street 1:11285 ELKINS RD
Practice Address - Street 2:D-4
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1259
Practice Address - Country:US
Practice Address - Phone:678-431-3901
Practice Address - Fax:770-521-0512
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004373101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional