Healthcare Provider Details

I. General information

NPI: 1508708249
Provider Name (Legal Business Name): TABLE COUNSELING AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2077 GREEN GATE PL
GRAYSON GA
30017-1857
US

IV. Provider business mailing address

911 DULUTH HIGHWAY # C-1B-315
LAWRENCEVILLE GA
30043
US

V. Phone/Fax

Practice location:
  • Phone: 404-496-8621
  • Fax:
Mailing address:
  • Phone: 404-496-8621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KELLEY WEST
Title or Position: OWNER
Credential: LCSW
Phone: 404-496-8621