Healthcare Provider Details

I. General information

NPI: 1487885265
Provider Name (Legal Business Name): FUNMILAYO MEJABI LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 04/14/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BENZ CT
FAYETTEVILLE GA
30214-3781
US

IV. Provider business mailing address

PO BOX 591
FAYETTEVILLE GA
30214-0591
US

V. Phone/Fax

Practice location:
  • Phone: 912-255-1010
  • Fax:
Mailing address:
  • Phone: 912-255-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC003971
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: