MEDICARE: DR. KELLI MCCORMICK BYNUM PHD

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	103T00000X	Psychologist	PSY001992	GA

General Provider Information

NPI Number	:	1194662403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLI MCCORMICK BYNUM PHD

Provider Business Mailing Address
First Line	:	4375 WIEUCA RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-3880
Country	:	US
Telephone Number	:	404-295-5905
Fax Number	:

Provider Business Practice Location Address
First Line	:	4375 WIEUCA RD NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-3880
Country	:	US
Telephone Number	:	404-295-5905
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2026
Last Update Date	:	05/04/2026

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