Basic Information
Provider Information | |||||||||
NPI: | 1881151769 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKS | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | AMANDA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CAADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1150 COUNTY ROAD 61 | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | AL | ||||||||
PostalCode: | 362744652 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3346469345 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 229 S DAVIS RD STE 900 | ||||||||
Address2: |   | ||||||||
City: | LAGRANGE | ||||||||
State: | GA | ||||||||
PostalCode: | 302412609 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7067561489 | ||||||||
FaxNumber: | 7067561493 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/27/2019 | ||||||||
LastUpdateDate: | 02/27/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C0291 | GA | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.