Healthcare Provider Details

I. General information

NPI: 1366155947
Provider Name (Legal Business Name): ELEVATED MENTAL HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 POINTCREST LN
GRAYSON GA
30017-4293
US

IV. Provider business mailing address

5900 SPOUT SPRINGS RD STE 3C
FLOWERY BRANCH GA
30542-6449
US

V. Phone/Fax

Practice location:
  • Phone: 470-238-9321
  • Fax:
Mailing address:
  • Phone: 470-238-9321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JERE COOPER
Title or Position: APRN
Credential: APRN
Phone: 678-467-8232