Healthcare Provider Details

I. General information

NPI: 1114559549
Provider Name (Legal Business Name): TRANSFORMATIVE THERAPY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 GEORGIA AVE SE STE 203
ATLANTA GA
30312-3000
US

IV. Provider business mailing address

1702 BOULDER WALK LN SE
ATLANTA GA
30316-3991
US

V. Phone/Fax

Practice location:
  • Phone: 470-377-5990
  • Fax:
Mailing address:
  • Phone: 770-789-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHADONNA DAVIS
Title or Position: CEO
Credential: PHD
Phone: 470-377-5990