Healthcare Provider Details

I. General information

NPI: 1588178487
Provider Name (Legal Business Name): NNK BEHAVIORAL HEALTH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1194 147TH ST STE 5
MONTICELLO GA
31064-8068
US

IV. Provider business mailing address

3826 SALEM RD # 136
COVINGTON GA
30016-4528
US

V. Phone/Fax

Practice location:
  • Phone: 678-561-3091
  • Fax: 404-795-8974
Mailing address:
  • Phone: 678-561-3091
  • Fax: 404-795-8974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8941
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8941
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. NICOLE N BENTON
Title or Position: CEO
Credential: LPC
Phone: 404-438-3677