Healthcare Provider Details

I. General information

NPI: 1578867982
Provider Name (Legal Business Name): RAVENS NEST FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 MULKEY RD STE 200
AUSTELL GA
30106-1364
US

IV. Provider business mailing address

1680 MULKEY RD STE 200
AUSTELL GA
30106-1364
US

V. Phone/Fax

Practice location:
  • Phone: 770-819-6825
  • Fax: 770-819-6826
Mailing address:
  • Phone: 770-819-6825
  • Fax: 770-819-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SHELBY GREEN
Title or Position: CEO
Credential:
Phone: 770-819-6825