=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831558931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PERSONAL RECOVERY NETWORK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2016
-----------------------------------------------------
Last Update Date | 08/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1640 POWERS FERRY RD SE BLDG 9 SUITE 330
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-5491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-831-0608
-----------------------------------------------------
Fax | 678-831-0564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1640 POWERS FERRY RD SE BLDG 9 SUITE 330
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-5491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-831-0608
-----------------------------------------------------
Fax | 678-831-0564
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. ASHLEY NICHOLS TAGTACHIAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-548-2589
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------