Provider Demographics
NPI:1487237277
Name:ASHLOCK, ANDREW T
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:T
Last Name:ASHLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4939 LOWER ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4338
Mailing Address - Country:US
Mailing Address - Phone:770-363-6213
Mailing Address - Fax:
Practice Address - Street 1:4939 LOWER ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4338
Practice Address - Country:US
Practice Address - Phone:770-363-6213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health