Healthcare Provider Details

I. General information

NPI: 1265304562
Provider Name (Legal Business Name): LIVING LOTUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 09/18/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BROADWAY AVENUE
BRASELTON GA
30517
US

IV. Provider business mailing address

PO BOX 637
BRASELTON GA
30517-0011
US

V. Phone/Fax

Practice location:
  • Phone: 470-236-8131
  • Fax: 706-310-8113
Mailing address:
  • Phone: 470-236-8131
  • Fax: 706-310-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. JESSICA SEXTON
Title or Position: OWNER
Credential: LPC
Phone: 470-236-8131