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General NPI Number Information
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NPI Number | 1164346052
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Entity Type | Organization
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Legal Business Name | 1730996273.
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Dates
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Enumeration Date | 08/05/2026
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Last Update Date | 08/05/2026
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Provider Practice Location Address
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Address Line | 2155 POST OAK TRITT RD STE 300
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City | MARIETTA
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State | GA
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Zip | 30062-1651
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Country | US
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Telephone | 678-383-9532
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Fax |
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Provider Business Mailing Address
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Address Line | 2721 BENCH CIR
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City | ELLENWOOD
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State | GA
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Zip | 30294-5510
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Country | US
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Telephone | 404-759-7213
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Fax |
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Authorized Official
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Title or Position | PMHNP
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Name | JONITA GREEN
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Credential | PMHNP
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Telephone | 404-759-7213
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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