MEDICARE: GROW HEAL LIVE LEAD LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	3256	GA

General Provider Information

NPI Number	:	1376858100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROW HEAL LIVE LEAD LLC

Provider Business Mailing Address
First Line	:	2964 PEACHTREE RD NW
Second Line	:	SUITE 760
City	:	ATLANTA
State	:	GA
Zip	:	30305-2153
Country	:	US
Telephone Number	:	678-463-1092
Fax Number	:

Provider Business Practice Location Address
First Line	:	2964 PEACHTREE RD NW
Second Line	:	SUITE 760
City	:	ATLANTA
State	:	GA
Zip	:	30305-2153
Country	:	US
Telephone Number	:	678-463-1092
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST/PRESIDENT
Name	:	DR. WENDY L DICKINSON
Credential	:	PH.D.
Telephone Number	:	678-463-1092

Provider Enumeration Date	:	08/17/2010
Last Update Date	:	08/17/2010

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