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General NPI Number Information
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NPI Number | 1417750811
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Entity Type | Individual
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Provider Name | BRUENETTER ELLIS WRIGHT ADDICTION COUNSELOR
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Gender | Female
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Dates
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Enumeration Date | 03/31/2025
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Last Update Date | 03/31/2025
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Provider Practice Location Address
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Address Line | 1957 LAKESIDE PKWY STE 510
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City | TUCKER
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State | GA
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Zip | 30084-5859
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Country | US
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Telephone | 404-289-0313
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Fax | 404-289-0314
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Provider Business Mailing Address
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Address Line | PO BOX 479
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City | AVONDALE ESTATES
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State | GA
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Zip | 30002-0479
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Country | US
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Telephone | 404-289-0313
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Fax | 404-289-0314
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 20245062T52
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License Number State | GA
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