Healthcare Provider Details

I. General information

NPI: 1205766706
Provider Name (Legal Business Name): MELAKIYA BRADLEY JOHNSON EDD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 CITRINE WAY
ACWORTH GA
30101-2107
US

IV. Provider business mailing address

113 CITRINE WAY
ACWORTH GA
30101-2107
US

V. Phone/Fax

Practice location:
  • Phone: 678-357-8724
  • Fax:
Mailing address:
  • Phone: 678-357-8724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC013376
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: