Healthcare Provider Details

I. General information

NPI: 1790514263
Provider Name (Legal Business Name): THE LIVING WELL AGENCY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 LANIER AVE E STE 2
FAYETTEVILLE GA
30214-1604
US

IV. Provider business mailing address

425 MERRYDALE DR
FAYETTEVILLE GA
30215-5422
US

V. Phone/Fax

Practice location:
  • Phone: 770-284-0560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: ADRIENNE LYNN MARSHALL
Title or Position: OWNER
Credential: LMFT
Phone: 770-284-0560