Healthcare Provider Details

I. General information

NPI: 1780296533
Provider Name (Legal Business Name): NORTH ATLANTA MENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2020
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1742 MOUNT VERNON RD STE 150B
ATLANTA GA
30338-4251
US

IV. Provider business mailing address

1742 MOUNT VERNON RD STE 150B
ATLANTA GA
30338-4251
US

V. Phone/Fax

Practice location:
  • Phone: 631-512-1567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN CIERZNIEWSKI
Title or Position: CEO
Credential:
Phone: 631-512-1567