Healthcare Provider Details

I. General information

NPI: 1619607363
Provider Name (Legal Business Name): MICHAEL JOHN LIRETTE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 PROFESSIONAL CIR STE B
MARTINEZ GA
30907-8234
US

IV. Provider business mailing address

2326 OVERTON RD
AUGUSTA GA
30904-3446
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-8855
  • Fax:
Mailing address:
  • Phone: 706-825-7126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: