Provider Demographics
NPI:1700355179
Name:REBA-HARRELSON, LAUREN EVELYN (PHD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:EVELYN
Last Name:REBA-HARRELSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:E
Other - Last Name:REBA-HARRELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:507 HARPER RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-4958
Mailing Address - Country:US
Mailing Address - Phone:919-923-2119
Mailing Address - Fax:
Practice Address - Street 1:507 HARPER RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-4958
Practice Address - Country:US
Practice Address - Phone:919-923-2119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003563103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical