Healthcare Provider Details

I. General information

NPI: 1063554913
Provider Name (Legal Business Name): LARRY DALE DEYTON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 E MAIN ST STE 10
BLUE RIDGE GA
30513-4534
US

IV. Provider business mailing address

990 E MAIN ST STE 10
BLUE RIDGE GA
30513-4534
US

V. Phone/Fax

Practice location:
  • Phone: 706-897-3011
  • Fax:
Mailing address:
  • Phone: 706-897-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC001871
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: