Basic Information
| Provider Information | |||||||||
| NPI: | 1992380281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLYBURN | ||||||||
| FirstName: | MARYAM | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1128 LAKEVIEW RD | ||||||||
| Address2: | |||||||||
| City: | GRAYSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300171143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709789393 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1128 LAKEVIEW RD | ||||||||
| Address2: | |||||||||
| City: | GRAYSON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300171143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702657076 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2021 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC001868 | GA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.