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General NPI Number Information
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NPI Number | 1932885530
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Entity Type | Organization
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Legal Business Name | PROVENANCE PSYCHIATRIC SERVICES LLC
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Dates
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Enumeration Date | 06/27/2023
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Last Update Date | 03/19/2025
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Provider Practice Location Address
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Address Line | 643 RAY LEWIS RD
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City | BLAIRSVILLE
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State | GA
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Zip | 30512-1439
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Country | US
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Telephone | 706-970-1948
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Fax | 877-930-7732
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Provider Business Mailing Address
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Address Line | 643 RAY LEWIS RD
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City | BLAIRSVILLE
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State | GA
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Zip | 30512-1439
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Country | US
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Telephone | 706-970-1948
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Fax | 877-930-7732
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Authorized Official
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Title or Position | OWNER
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Name | BRIAN KENT JOHNSON
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Credential | APRN
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Telephone | 610-453-1548
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 364SP0808X
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Taxonomy Name | Psychiatric/Mental Health Clinical Nurse Specialist
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License Number |
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License Number State |
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