Healthcare Provider Details

I. General information

NPI: 1043834724
Provider Name (Legal Business Name): RENEWED & RESTORED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 BRIARCLIFF RD NE STE 203
ATLANTA GA
30329-3017
US

IV. Provider business mailing address

2218 RUGBY AVE
ATLANTA GA
30337-1019
US

V. Phone/Fax

Practice location:
  • Phone: 678-849-4777
  • Fax:
Mailing address:
  • Phone: 678-849-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLY M HARRIS
Title or Position: OWNER
Credential: LPC, NCC, CPCS
Phone: 678-849-4777