Healthcare Provider Details

I. General information

NPI: 1104273234
Provider Name (Legal Business Name): THE BRANCH HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 CENTER ST
COLLIERVILLE TN
38017
US

IV. Provider business mailing address

5737 OLD NATIONAL HIGHWAY 300
ATLANTA GA
30349
US

V. Phone/Fax

Practice location:
  • Phone: 678-834-7615
  • Fax: 678-834-7616
Mailing address:
  • Phone: 678-834-7615
  • Fax: 678-834-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. NIKKI WRIGHT
Title or Position: OWNER
Credential:
Phone: 678-834-7615