MEDICARE: AKIDA LAVENDER LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC016148	GA

General Provider Information

NPI Number	:	1114887122
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AKIDA LAVENDER LPC

Provider Business Mailing Address
First Line	:	1524 GORDON BOW LN SW
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126-2110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1524 GORDON BOW LN SW
Second Line	:
City	:	MABLETON
State	:	GA
Zip	:	30126-2110
Country	:	US
Telephone Number	:	770-743-7037
Fax Number	:	770-743-7037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2025
Last Update Date	:	11/19/2025

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Directions to “ AKIDA LAVENDER LPC” Practice Location

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