Provider Demographics
NPI:1679067870
Name:ATL SPORT
Entity type:Organization
Organization Name:ATL SPORT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSE PROFESSIONAL COUSELER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, MBA, MAMFT, NCC
Authorized Official - Phone:404-625-6262
Mailing Address - Street 1:5376 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30260-3557
Mailing Address - Country:US
Mailing Address - Phone:404-748-1102
Mailing Address - Fax:
Practice Address - Street 1:5376 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:GA
Practice Address - Zip Code:30260
Practice Address - Country:US
Practice Address - Phone:404-748-1102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIT MIND, FIT BODY, FIT SOUL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1396092912OtherNPPES