Healthcare Provider Details

I. General information

NPI: 1528774916
Provider Name (Legal Business Name): PSYCHIATRY AND WELLNESS OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 COLONIAL PARK DR STE 100
ROSWELL GA
30075-3746
US

IV. Provider business mailing address

620 COLONIAL PARK DR STE 100
ROSWELL GA
30075-3746
US

V. Phone/Fax

Practice location:
  • Phone: 678-439-0017
  • Fax: 678-884-0761
Mailing address:
  • Phone: 678-439-0017
  • Fax: 678-884-0761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JOHN KANYUIRA
Title or Position: PRESIDENT
Credential:
Phone: 678-439-0017