MEDICARE: HALEY AUGUSTA GRESHAM MS, LMFT

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	106H00000X	Marriage & Family Therapist	LMFT001591	GA

General Provider Information

NPI Number	:	1790298768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALEY AUGUSTA GRESHAM MS, LMFT

Provider Business Mailing Address
First Line	:	151 MCDONALD RD
Second Line	:
City	:	SHARPSBURG
State	:	GA
Zip	:	30277-2706
Country	:	US
Telephone Number	:	770-845-3666
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 GOVERNORS SQ STE E
Second Line	:
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-4866
Country	:	US
Telephone Number	:	770-845-3666
Fax Number	:

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

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	11/13/2017

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