Healthcare Provider Details

I. General information

NPI: 1144821265
Provider Name (Legal Business Name): THE GREEN SHELF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 NEWRY DR
ATLANTA GA
30349-8112
US

IV. Provider business mailing address

154 NEWRY DR
ATLANTA GA
30349-8112
US

V. Phone/Fax

Practice location:
  • Phone: 470-227-1079
  • Fax:
Mailing address:
  • Phone: 678-687-4405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. APRIL DENISE BROWN
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 470-227-1079