Healthcare Provider Details

I. General information

NPI: 1659094704
Provider Name (Legal Business Name): ESE MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2022
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 OLD VALDOSTA RD
RAY CITY GA
31645-7132
US

IV. Provider business mailing address

1539 OLD VALDOSTA RD
RAY CITY GA
31645-7132
US

V. Phone/Fax

Practice location:
  • Phone: 706-480-4322
  • Fax:
Mailing address:
  • Phone: 877-755-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: WENDY PEARSON
Title or Position: OWNER
Credential: NP
Phone: 229-356-1360