=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427803063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHEERFUL THERAPY GROUP OF GEORGIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2024
-----------------------------------------------------
Last Update Date | 04/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2221 PEACHTREE ROAD SUITE D-397
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-451-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2221 PEACHTREE ROAD SUITE D-397
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-451-1700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING DIRECTOR
-----------------------------------------------------
Name | NICHOLAS HAWKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-451-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084B0040X
-----------------------------------------------------
Taxonomy Name | Behavioral Neurology & Neuropsychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------