Healthcare Provider Details

I. General information

NPI: 1144565284
Provider Name (Legal Business Name): LEEANN ROCHELLE GUMULAUSKAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEEANN ROCHELLE SMITH

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 GLOUCESTER ST STE 117
BRUNSWICK GA
31520-7030
US

IV. Provider business mailing address

1093 TAMARA DR SE
DARIEN GA
31305-4257
US

V. Phone/Fax

Practice location:
  • Phone: 912-244-9919
  • Fax:
Mailing address:
  • Phone: 715-379-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701008515
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4949-125
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC013249
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: