Provider Demographics
NPI:1326515040
Name:OSBORNE, MICHAEL LAMONT (CADC-II,ICADC,MATS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAMONT
Last Name:OSBORNE
Suffix:
Gender:M
Credentials:CADC-II,ICADC,MATS
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:LAMONT
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2232
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-2232
Mailing Address - Country:US
Mailing Address - Phone:678-532-4366
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3255
Practice Address - Country:US
Practice Address - Phone:678-532-4366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1394101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051350043OtherDRIVER'S LICENSE