Healthcare Provider Details

I. General information

NPI: 1306537766
Provider Name (Legal Business Name): LAUREN F PETRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2023
Last Update Date: 06/06/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 PLEASANT HOME RD STE A
AUGUSTA GA
30907-3518
US

IV. Provider business mailing address

114 PLEASANT HOME RD
AUGUSTA GA
30907-3518
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-3209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8282
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC013687
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: