Healthcare Provider Details

I. General information

NPI: 1427807460
Provider Name (Legal Business Name): ELLISTON PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 TECHNOLOGY PKWY STE 600
PEACHTREE CORNERS GA
30092-3489
US

IV. Provider business mailing address

11560 GREAT OAKS WAY STE 300
ALPHARETTA GA
30022-2453
US

V. Phone/Fax

Practice location:
  • Phone: 404-474-0040
  • Fax: 404-704-0895
Mailing address:
  • Phone: 404-474-0040
  • Fax: 404-704-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: A KAY
Title or Position: MANAGER
Credential:
Phone: 404-474-0040