MEDICARE: EDLYN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1154935450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDLYN LLC

Provider Business Mailing Address
First Line	:	3267 WATSON MEADOW LN
Second Line	:
City	:	LOGANVILLE
State	:	GA
Zip	:	30052-8297
Country	:	US
Telephone Number	:	718-747-9494
Fax Number	:

Provider Business Practice Location Address
First Line	:	1880 BRASELTON HWY # 118-5174
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-2852
Country	:	US
Telephone Number	:	470-460-5568
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	VICTOR T GRIMES
Credential	:
Telephone Number	:	800-540-9963

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	08/02/2022

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Directions to “EDLYN LLC ” Practice Location

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