=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366018541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENVISIONED PURPOSE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2021
-----------------------------------------------------
Last Update Date | 03/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1477 S BETHANY RD
-----------------------------------------------------
City | LOCUST GROVE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-765-8770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2045 MOUNT ZION RD # 126
-----------------------------------------------------
City | MORROW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-3313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | DR. KRISTINA NEMARD
-----------------------------------------------------
Credential | PHD LPC
-----------------------------------------------------
Telephone | 678-463-0324
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------