=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821221425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRILLIUM SPRINGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2009
-----------------------------------------------------
Last Update Date | 08/29/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 POWERS FERRY RD SE BUILDING 16 SUITE 300
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-5491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-310-6120
-----------------------------------------------------
Fax | 770-612-1999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1640 POWERS FERRY RD SE BUILDING 16 SUITE 300
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-5491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-310-6120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | VILDA S BRANNEN
-----------------------------------------------------
Credential | M.S., L.P.C.
-----------------------------------------------------
Telephone | 404-310-6120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | LPC004368
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------