Healthcare Provider Details

I. General information

NPI: 1134792435
Provider Name (Legal Business Name): LISA FUTCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2021
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 BLOUNT CROSSING RD SE
DARIEN GA
31305-3300
US

IV. Provider business mailing address

1026 BLOUNT CROSSING RD SE
DARIEN GA
31305-3300
US

V. Phone/Fax

Practice location:
  • Phone: 478-494-2052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name: LISA FUTCH
Title or Position: PRESIDENT
Credential: LPC
Phone: 478-494-2052