Healthcare Provider Details

I. General information

NPI: 1871890269
Provider Name (Legal Business Name): KEVIN F DALY M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5205 STILESBORO RD NW STE 225
KENNESAW GA
30152-7748
US

IV. Provider business mailing address

PO BOX 801096
ACWORTH GA
30101-1096
US

V. Phone/Fax

Practice location:
  • Phone: 678-278-8345
  • Fax: 800-634-6360
Mailing address:
  • Phone: 770-314-0293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number09103511
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number575
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: