Healthcare Provider Details

I. General information

NPI: 1083880744
Provider Name (Legal Business Name): WELLSTAR NEUROPSYCHOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2008
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

IV. Provider business mailing address

677 CHURCH ST NE
MARIETTA GA
30060-1101
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-6695
  • Fax: 770-793-7997
Mailing address:
  • Phone: 770-793-6695
  • Fax: 770-793-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. NICOLE ASHE
Title or Position: EXECUTIVE DIRECTOR OF FINANCE
Credential:
Phone: 770-792-5261