Healthcare Provider Details

I. General information

NPI: 1861172348
Provider Name (Legal Business Name): MANIFESTED WELLNESS THERAPEUTIC SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 WINDY HILL RD SE STE 210
MARIETTA GA
30067-8644
US

IV. Provider business mailing address

2451 CUMBERLAND PKWY SE STE 3423
ATLANTA GA
30339-6136
US

V. Phone/Fax

Practice location:
  • Phone: 678-631-6053
  • Fax:
Mailing address:
  • Phone: 678-631-6053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ADRIENNE WARREN
Title or Position: OWNER
Credential:
Phone: 678-631-6053