=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023831492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN MCCUTCHEN DACK LPC, LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5755 N POINT PKWY STE 248
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-1173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-913-1102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 275 SEALE LN
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30022-6137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-695-6811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | MFT1280
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------