Healthcare Provider Details

I. General information

NPI: 1063341899
Provider Name (Legal Business Name): KALEIDOSCOPE COGNITIVE LEARNING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 DEL LAGO CIR NW
KENNESAW GA
30152-8285
US

IV. Provider business mailing address

2090 DEL LAGO CIR NW
KENNESAW GA
30152-8285
US

V. Phone/Fax

Practice location:
  • Phone: 770-403-9582
  • Fax:
Mailing address:
  • Phone: 770-403-9582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANDRA MOTHLAND SUTTON
Title or Position: CEO/SUBSTANCE ABUSE COUNSELOR
Credential: CACII
Phone: 770-403-9582