Provider Demographics
NPI:1053005512
Name:KNELLER, CALYPSO-JADE
Entity type:Individual
Prefix:
First Name:CALYPSO-JADE
Middle Name:
Last Name:KNELLER
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 1:309 PIRKLE FERRY RD STE B100
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2548
Mailing Address - Country:US
Mailing Address - Phone:470-206-8250
Mailing Address - Fax:
Practice Address - Street 1:309 PIRKLE FERRY RD STE B100
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2548
Practice Address - Country:US
Practice Address - Phone:470-206-8250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC008684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health