Healthcare Provider Details

I. General information

NPI: 1376112912
Provider Name (Legal Business Name): LAKESHA WYNN CRC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

3599 OAKVALE FALLS CT
DECATUR GA
30034-6930
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2394
  • Fax:
Mailing address:
  • Phone: 678-634-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number477236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: