Provider Demographics
NPI:1215103767
Name:ATLANTA CENTER FOR FAMILY WELLNESS, LLC
Entity type:Organization
Organization Name:ATLANTA CENTER FOR FAMILY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:III
Authorized Official - Credentials:PSYD
Authorized Official - Phone:404-550-9981
Mailing Address - Street 1:PO BOX 7730
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30357-0730
Mailing Address - Country:US
Mailing Address - Phone:404-550-9981
Mailing Address - Fax:
Practice Address - Street 1:1401 PEACHTREE ST NE STE 210
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-3000
Practice Address - Country:US
Practice Address - Phone:404-550-9981
Practice Address - Fax:404-475-4880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002857103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA624392123AMedicaid