Healthcare Provider Details

I. General information

NPI: 1699216218
Provider Name (Legal Business Name): MARCUS LUSK M.A., A.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2017
Last Update Date: 03/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 DUNWOODY PARK DRIVE SUITE 136
ATLANTA GA
30338
US

IV. Provider business mailing address

701 WALDAN LN
ACWORTH GA
30102-7112
US

V. Phone/Fax

Practice location:
  • Phone: 770-744-5055
  • Fax:
Mailing address:
  • Phone: 770-828-9851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC005811
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: