Provider Demographics
NPI:1346691540
Name:IRVINE, GERA (LPC)
Entity Type:Individual
Prefix:
First Name:GERA
Middle Name:
Last Name:IRVINE
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 1:105 WILLIAM WAY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-6160
Mailing Address - Country:US
Mailing Address - Phone:478-327-7683
Mailing Address - Fax:478-781-1395
Practice Address - Street 1:105 WILLIAM WAY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-6160
Practice Address - Country:US
Practice Address - Phone:478-327-7683
Practice Address - Fax:478-781-1395
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC3186101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional