Provider Demographics
NPI:1700552783
Name:HUSTON, MICHELLE-DAWNE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE-DAWNE
Middle Name:
Last Name:HUSTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4045 FIVE FORKS TRICKUM RD SW STE D17204
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2538
Mailing Address - Country:US
Mailing Address - Phone:404-384-0564
Mailing Address - Fax:
Practice Address - Street 1:4045 FIVE FORKS TRICKUM RD SW STE D17204
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2538
Practice Address - Country:US
Practice Address - Phone:404-384-0564
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040142611041C0700X
GACSW0075611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical