Provider Demographics
NPI:1205845294
Name:NETTLES, RAE LYNN (LPC, MFT)
Entity Type:Individual
Prefix:MS
First Name:RAE
Middle Name:LYNN
Last Name:NETTLES
Suffix:
Gender:F
Credentials:LPC, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7505 WATERS AVE
Mailing Address - Street 2:D-5
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-3825
Mailing Address - Country:US
Mailing Address - Phone:912-656-4227
Mailing Address - Fax:912-257-4407
Practice Address - Street 1:7505 WATERS AVE
Practice Address - Street 2:D-5
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3825
Practice Address - Country:US
Practice Address - Phone:912-656-4227
Practice Address - Fax:912-257-4407
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002975101YP2500X
GA001054106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA451297230AMedicaid