Healthcare Provider Details

I. General information

NPI: 1740682277
Provider Name (Legal Business Name): MEGAN BRACKETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MIZE ST
LA FAYETTE GA
30728-3346
US

IV. Provider business mailing address

PO BOX 1028
LA FAYETTE GA
30728-1028
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-5591
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC004343
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: