=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053118018
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIANNA LEWALLEN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2025
-----------------------------------------------------
Last Update Date | 03/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 331 MEADOW LARK WAY
-----------------------------------------------------
City | MAYSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30558-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-908-4889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 331 MEADOW LARK WAY
-----------------------------------------------------
City | MAYSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30558-1946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC015490
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------