Healthcare Provider Details

I. General information

NPI: 1992380281
Provider Name (Legal Business Name): MARYAM CLYBURN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1128 LAKEVIEW RD
GRAYSON GA
30017-1143
US

IV. Provider business mailing address

1128 LAKEVIEW RD
GRAYSON GA
30017-1143
US

V. Phone/Fax

Practice location:
  • Phone: 770-265-7076
  • Fax:
Mailing address:
  • Phone: 770-978-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC001868
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: