Healthcare Provider Details

I. General information

NPI: 1558275560
Provider Name (Legal Business Name): MARIYAH RENEE CROSS LAPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 PONDER PLACE DR
EVANS GA
30809-3186
US

IV. Provider business mailing address

112 LARIAT CIR
EVANS GA
30809-4101
US

V. Phone/Fax

Practice location:
  • Phone: 762-224-3027
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC011471
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: