Basic Information
| Provider Information | |||||||||
| NPI: | 1881644623 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEDERMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | EDS, LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 HENRY CLOWER BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300783152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
| FaxNumber: | 7709789324 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 HENRY CLOWER BLVD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300783152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
| FaxNumber: | 7709789324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 000665 | GA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.