Healthcare Provider Details

I. General information

NPI: 1407683295
Provider Name (Legal Business Name): WISTERIA PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 N DRUID HILLS RD NE STE 280
ATLANTA GA
30329-3141
US

IV. Provider business mailing address

2250 N DRUID HILLS RD NE STE 280
ATLANTA GA
30329-3141
US

V. Phone/Fax

Practice location:
  • Phone: 404-282-8846
  • Fax:
Mailing address:
  • Phone: 678-558-9428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: NADRAT NUHU
Title or Position: PSYCHOLOGIST
Credential:
Phone: 678-558-9428