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General NPI Number Information
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NPI Number | 1154935450
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Entity Type | Organization
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Legal Business Name | EDLYN LLC
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Dates
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Enumeration Date | 09/03/2020
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Last Update Date | 08/02/2022
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Provider Practice Location Address
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Address Line | 1880 BRASELTON HWY # 118-5174
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-2852
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Country | US
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Telephone | 470-460-5568
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Fax |
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Provider Business Mailing Address
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Address Line | 3267 WATSON MEADOW LN
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City | LOGANVILLE
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State | GA
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Zip | 30052-8297
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Country | US
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Telephone | 718-747-9494
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | VICTOR T GRIMES
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Credential |
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Telephone | 800-540-9963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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