Provider Demographics
NPI:1982002267
Name:MCINTYRE, MISTY LANE (MS, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:MISTY
Middle Name:LANE
Last Name:MCINTYRE
Suffix:
Gender:F
Credentials:MS, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 NEWNAN ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3428
Mailing Address - Country:US
Mailing Address - Phone:770-214-9811
Mailing Address - Fax:
Practice Address - Street 1:605 NEWNAN ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3428
Practice Address - Country:US
Practice Address - Phone:770-214-9811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001337106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist