Provider Demographics
NPI:1073386280
Name:LAVENDER MOUNTAIN COUNSELING
Entity Type:Organization
Organization Name:LAVENDER MOUNTAIN COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:706-450-4029
Mailing Address - Street 1:111 BRIDGEPOINT PLZ STE 120
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3056
Mailing Address - Country:US
Mailing Address - Phone:706-450-4029
Mailing Address - Fax:
Practice Address - Street 1:111 BRIDGEPOINT PLZ STE 120
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3056
Practice Address - Country:US
Practice Address - Phone:706-450-4029
Practice Address - Fax:706-810-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-31
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty