Healthcare Provider Details

I. General information

NPI: 1447169784
Provider Name (Legal Business Name): BUILT-EMPOWERED-EQUIPPED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 ROCK SHADOW CT
STONE MOUNTAIN GA
30087-5644
US

IV. Provider business mailing address

8170 MALL PKWY # 1250
LITHONIA GA
30038-2545
US

V. Phone/Fax

Practice location:
  • Phone: 470-287-3699
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JASMINE GHOLSTON
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential: LPC
Phone: 470-287-3699