MEDICARE: LALAH MANLY M.ED.

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1205402435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LALAH MANLY M.ED.

Provider Business Mailing Address
First Line	:	PO BOX 807
Second Line	:
City	:	PINE LAKE
State	:	GA
Zip	:	30072-0807
Country	:	US
Telephone Number	:	404-683-0597
Fax Number	:

Provider Business Practice Location Address
First Line	:	1986 HOSEA L WILLIAMS DR NE STE C
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30317-2225
Country	:	US
Telephone Number	:	470-781-4589
Fax Number	:

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

Provider Enumeration Date	:	05/28/2021
Last Update Date	:	05/28/2021

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