Healthcare Provider Details

I. General information

NPI: 1023841731
Provider Name (Legal Business Name): SOUTHERN LIVE OAK WELLNESS PSYCHIATRIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4828 ASHFORD DUNWOODY RD STE 100
ATLANTA GA
30338-4833
US

IV. Provider business mailing address

4828 ASHFORD DUNWOODY RD STE 100
ATLANTA GA
30338-4833
US

V. Phone/Fax

Practice location:
  • Phone: 770-238-2674
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH KUECHER
Title or Position: CEO
Credential:
Phone: 404-951-6020