Healthcare Provider Details

I. General information

NPI: 1073841862
Provider Name (Legal Business Name): MICHELLE K LYN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W PONCE DE LEON AVE SUITE 552
DECATUR GA
30030-2400
US

IV. Provider business mailing address

PO BOX 372515
DECATUR GA
30037-2515
US

V. Phone/Fax

Practice location:
  • Phone: 678-643-1786
  • Fax:
Mailing address:
  • Phone: 678-643-1786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY002974
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: