Healthcare Provider Details

I. General information

NPI: 1215889126
Provider Name (Legal Business Name): SANDY PLAINS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2026
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 SHALLOWFORD RD STE 1300
MARIETTA GA
30062-7033
US

IV. Provider business mailing address

3225 SHALLOWFORD RD STE 1300
MARIETTA GA
30062-7033
US

V. Phone/Fax

Practice location:
  • Phone: 678-560-7160
  • Fax:
Mailing address:
  • Phone: 678-560-7160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN GLAESER
Title or Position: MANAGING PARTNER
Credential:
Phone: 678-560-5278