Provider Demographics
NPI:1457990616
Name:LANNON, KELLY (LPC, LCMHC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LANNON
Suffix:
Gender:F
Credentials:LPC, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4325 1ST AVE UNIT 2756
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30085-0330
Mailing Address - Country:US
Mailing Address - Phone:470-485-3938
Mailing Address - Fax:
Practice Address - Street 1:1123 CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1207
Practice Address - Country:US
Practice Address - Phone:470-485-3938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-04
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012140101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty