Provider Demographics
NPI:1902218134
Name:LESANE, EVERICK SCOTT (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:EVERICK
Middle Name:SCOTT
Last Name:LESANE
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 POSTMASTER DR
Mailing Address - Street 2:#3092
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2838
Mailing Address - Country:US
Mailing Address - Phone:404-795-2111
Mailing Address - Fax:
Practice Address - Street 1:200 W CAMPGROUND RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-8002
Practice Address - Country:US
Practice Address - Phone:404-795-2111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-22
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003175654AMedicaid