Healthcare Provider Details

I. General information

NPI: 1164346052
Provider Name (Legal Business Name): 1730996273.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 POST OAK TRITT RD STE 300
MARIETTA GA
30062-1651
US

IV. Provider business mailing address

2721 BENCH CIR
ELLENWOOD GA
30294-5510
US

V. Phone/Fax

Practice location:
  • Phone: 678-383-9532
  • Fax:
Mailing address:
  • Phone: 404-759-7213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JONITA GREEN
Title or Position: PMHNP
Credential: PMHNP
Phone: 404-759-7213