Healthcare Provider Details

I. General information

NPI: 1255077061
Provider Name (Legal Business Name): SUCCESS BRAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11630 GA-100
FRANKLIN GA
30217
US

IV. Provider business mailing address

931 MONROE DR NE STE A
ATLANTA GA
30308-1793
US

V. Phone/Fax

Practice location:
  • Phone: 404-466-2050
  • Fax:
Mailing address:
  • Phone: 404-466-2050
  • Fax: 478-779-1175

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JOHN KENNEBREW
Title or Position: OWNER
Credential:
Phone: 404-466-2050