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General NPI Number Information
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NPI Number | 1114552874
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Entity Type | Organization
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Legal Business Name | LIVINGWELL COLLABORATIVE, LLC
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Dates
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Enumeration Date | 03/03/2020
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Last Update Date | 04/17/2020
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Provider Practice Location Address
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Address Line | 2751 BUFORD HWY NE STE 410
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City | ATLANTA
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State | GA
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Zip | 30324-5457
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Country | US
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Telephone | 404-689-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 6875 PEACHTREE DUNWOODY RD APT 312
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City | ATLANTA
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State | GA
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Zip | 30328-5727
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Country | US
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Telephone | 404-787-6146
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PATRICIA SCRUGGS
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Credential | LPC
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Telephone | 404-689-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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