Healthcare Provider Details

I. General information

NPI: 1194662403
Provider Name (Legal Business Name): KELLI MCCORMICK BYNUM PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4375 WIEUCA RD NE
ATLANTA GA
30342-3880
US

IV. Provider business mailing address

4375 WIEUCA RD NE
ATLANTA GA
30342-3880
US

V. Phone/Fax

Practice location:
  • Phone: 404-295-5905
  • Fax:
Mailing address:
  • Phone: 404-295-5905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY001992
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: