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General NPI Number Information
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NPI Number | 1073742482
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Entity Type | Organization
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Legal Business Name | WELLSTAR PEDIATRIC & FAMILY WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 07/07/2009
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Last Update Date | 07/07/2009
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Provider Practice Location Address
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Address Line | 1810 MULKEY RD SUITE 201
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City | AUSTELL
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State | GA
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Zip | 30106-1151
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Country | US
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Telephone | 770-634-2349
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Fax | 770-819-0597
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Provider Business Mailing Address
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Address Line | 1810 MULKEY RD SUITE 201
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City | AUSTELL
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State | GA
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Zip | 30106-1151
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Country | US
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Telephone | 770-634-2349
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Fax | 770-819-0597
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Authorized Official
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Title or Position | ASST; VP OF FINANCE
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Name | NICOLE ASHE
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Credential |
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Telephone | 770-792-5261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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