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General NPI Number Information
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NPI Number | 1730999665
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Entity Type | Organization
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Legal Business Name | WELLCREST THERAPY
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Dates
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Enumeration Date | 01/13/2025
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Last Update Date | 01/13/2025
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Provider Practice Location Address
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Address Line | 3340 GARDENSIDE DR
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City | LOGANVILLE
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State | GA
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Zip | 30052
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Country | US
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Telephone | 470-495-7545
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 RIVERSIDE PKWY STE 128
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City | LAWRENCEVILLE
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State | GA
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Zip | 30043-5936
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Country | US
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Telephone | 470-495-7545
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | OLADUNNI F FAMINU
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Credential |
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Telephone | 470-495-7545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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