Healthcare Provider Details

I. General information

NPI: 1114552874
Provider Name (Legal Business Name): LIVINGWELL COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 04/17/2020
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 BUFORD HWY NE STE 410
ATLANTA GA
30324-5457
US

IV. Provider business mailing address

6875 PEACHTREE DUNWOODY RD APT 312
ATLANTA GA
30328-5727
US

V. Phone/Fax

Practice location:
  • Phone: 404-689-7100
  • Fax:
Mailing address:
  • Phone: 404-787-6146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA SCRUGGS
Title or Position: OWNER
Credential: LPC
Phone: 404-689-7100