Healthcare Provider Details

I. General information

NPI: 1932813052
Provider Name (Legal Business Name): DRLULLABY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 NORTHSIDE DR NW STE A7
ATLANTA GA
30318-2695
US

IV. Provider business mailing address

1440 W TAYLOR ST # 556
CHICAGO IL
60607-4623
US

V. Phone/Fax

Practice location:
  • Phone: 844-475-3379
  • Fax: 855-644-2982
Mailing address:
  • Phone: 844-475-3379
  • Fax: 855-644-2982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LISA ANN MEDALIE
Title or Position: CEO
Credential:
Phone: 619-997-5759