Healthcare Provider Details

I. General information

NPI: 1629492053
Provider Name (Legal Business Name): GEORGIA CENTER FOR MENTAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 ATLANTA RD SE
SMYRNA GA
30080-8255
US

IV. Provider business mailing address

563 IVEY WAY SE
MABLETON GA
30126-4563
US

V. Phone/Fax

Practice location:
  • Phone: 678-438-9084
  • Fax: 770-825-9120
Mailing address:
  • Phone: 678-438-9084
  • Fax: 770-825-9120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004377
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier003122272B
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MRS. KARA BECKETT COLEMAN
Title or Position: CEO
Credential: MSW, LCSW
Phone: 678-438-9084