Healthcare Provider Details

I. General information

NPI: 1619600178
Provider Name (Legal Business Name): UPLIFTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 07/02/2022
Certification Date: 07/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3654 S MARLBOROUGH DR
TUCKER GA
30084-8313
US

IV. Provider business mailing address

3654 S MARLBOROUGH DR
TUCKER GA
30084-8313
US

V. Phone/Fax

Practice location:
  • Phone: 404-376-1104
  • Fax:
Mailing address:
  • Phone: 404-376-1104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RAE K SIROTT
Title or Position: FOUNDER
Credential: LCSW
Phone: 404-376-1104