Provider Demographics
NPI:1013591270
Name:TWILLEY, BRENDA KAYLENE (LPC)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAYLENE
Last Name:TWILLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3000
Mailing Address - Country:US
Mailing Address - Phone:678-315-6811
Mailing Address - Fax:
Practice Address - Street 1:230 W COLLEGE ST STE D
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4249
Practice Address - Country:US
Practice Address - Phone:678-688-3133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty