Provider Demographics
NPI:1760414387
Name:ETIENNE, MIREILLE (LPC)
Entity Type:Individual
Prefix:MS
First Name:MIREILLE
Middle Name:
Last Name:ETIENNE
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 1:1 W COURT SQ
Mailing Address - Street 2:SUITE 750
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2538
Mailing Address - Country:US
Mailing Address - Phone:866-298-3447
Mailing Address - Fax:866-261-5260
Practice Address - Street 1:114 NEW ST
Practice Address - Street 2:SUITE G-4
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-4132
Practice Address - Country:US
Practice Address - Phone:770-885-2855
Practice Address - Fax:678-418-6540
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004290101YP2500X
NY005172101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health