Healthcare Provider Details

I. General information

NPI: 1710424692
Provider Name (Legal Business Name): MELISSA KENNEDY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2733 INVERNESS DR
HEPHZIBAH GA
30815
US

IV. Provider business mailing address

8735 DUNWOODY PLACE STE R
ATLANTA GA
30350
US

V. Phone/Fax

Practice location:
  • Phone: 404-585-1804
  • Fax:
Mailing address:
  • Phone: 404-585-1804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC016566
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: