Healthcare Provider Details

I. General information

NPI: 1639604705
Provider Name (Legal Business Name): LODRICK WEBBER APRN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 MALL OF GEORGIA BLVD APT 1427
BUFORD GA
30519-5541
US

IV. Provider business mailing address

2620 MALL OF GEORGIA BLVD APT 1427
BUFORD GA
30519-5541
US

V. Phone/Fax

Practice location:
  • Phone: 718-506-5520
  • Fax:
Mailing address:
  • Phone: 718-506-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number301605
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: