Healthcare Provider Details

I. General information

NPI: 1124615737
Provider Name (Legal Business Name): HOLISTIC ATLANTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2020
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6886 MAIN ST
STONECREST GA
30058-4508
US

IV. Provider business mailing address

3247 ROCKVIEW DR STE A
STONECREST GA
30038-3032
US

V. Phone/Fax

Practice location:
  • Phone: 404-808-0870
  • Fax: 470-201-1205
Mailing address:
  • Phone: 404-808-0870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. VAUGHN GAY
Title or Position: EXECUTIVE DIRECTOR
Credential: DSW, LPC
Phone: 404-808-0870