Provider Demographics
NPI:1891187829
Name:BYRD, EDITH (LPC007444)
Entity Type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:
Last Name:BYRD
Suffix:
Gender:F
Credentials:LPC007444
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 72001
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-2001
Mailing Address - Country:US
Mailing Address - Phone:678-423-3200
Mailing Address - Fax:770-683-3029
Practice Address - Street 1:15 PERRY ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1918
Practice Address - Country:US
Practice Address - Phone:678-423-3200
Practice Address - Fax:770-683-3029
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007444101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003150243AMedicaid