Provider Demographics
NPI:1861878126
Name:SOUTHERN OAKS COUNSELING, LLC
Entity type:Organization
Organization Name:SOUTHERN OAKS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TASHA
Authorized Official - Middle Name:ANDREA
Authorized Official - Last Name:PRITCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:253-988-7536
Mailing Address - Street 1:2128 CIRCULAR DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2128 CIRCULAR DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2808
Practice Address - Country:US
Practice Address - Phone:706-312-6761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-09
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC113761041C0700X
GACSW0055351041C0700X
GACSW0056141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003163121AMedicaid