=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720853377
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAYLA LUSTOSA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2023
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2675 MALL OF GEORGIA BLVD STE 102
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519-8783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-201-5717
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 PR SMITH BLVD
-----------------------------------------------------
City | WINDER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30680-8023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-574-0359
-----------------------------------------------------
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 | LPC015492
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------