=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982981353
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TREMAYNE GRAYDON MS, LPC, CPHQ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2011
-----------------------------------------------------
Last Update Date | 08/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4151 MEMORIAL DR STE 103A
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30032-1511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-492-8899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 BEAVERBROOK LN
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30215-5269
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-492-8899
-----------------------------------------------------
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 | APC002981
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC007943
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------