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General NPI Number Information
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NPI Number | 1669056313
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Entity Type | Organization
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Legal Business Name | SUCCESS DYNAMICS INCORPORATED
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 05/10/2021
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Provider Practice Location Address
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Address Line | 2056 W PARK PLACE BLVD STE D
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3537
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Country | US
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Telephone | 678-318-3622
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Fax |
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Provider Business Mailing Address
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Address Line | 2056 W PARK PLACE BLVD STE D
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3537
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Country | US
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Telephone | 678-318-3622
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. CALVIN OLIVER ELLISON
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Credential |
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Telephone | 252-717-5930
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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