Provider Demographics
NPI:1619607363
Name:LIRETTE, MICHAEL JOHN JR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:LIRETTE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2326 OVERTON RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3446
Mailing Address - Country:US
Mailing Address - Phone:706-825-7126
Mailing Address - Fax:
Practice Address - Street 1:3506 PROFESSIONAL CIR STE B
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-8234
Practice Address - Country:US
Practice Address - Phone:706-210-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional