Healthcare Provider Details

I. General information

NPI: 1811589294
Provider Name (Legal Business Name): RTD WELLNESS AND BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MARTIN LUTHER KING JR DR SW STE 201
ATLANTA GA
30310-1101
US

IV. Provider business mailing address

2290 LAKE ROYALE DR
RIVERDALE GA
30296-1896
US

V. Phone/Fax

Practice location:
  • Phone: 404-476-5498
  • Fax:
Mailing address:
  • Phone: 678-709-8002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: DESIREA RUSSELL
Title or Position: CFO/OWNER
Credential: MS, LPC
Phone: 678-709-8002