Provider Demographics
NPI:1417750811
Name:ELLIS WRIGHT, BRUENETTER (ADDICTION COUNSELOR)
Entity type:Individual
Prefix:
First Name:BRUENETTER
Middle Name:
Last Name:ELLIS WRIGHT
Suffix:
Gender:
Credentials:ADDICTION COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0479
Mailing Address - Country:US
Mailing Address - Phone:404-289-0313
Mailing Address - Fax:404-289-0314
Practice Address - Street 1:1957 LAKESIDE PKWY STE 510
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5859
Practice Address - Country:US
Practice Address - Phone:404-289-0313
Practice Address - Fax:404-289-0314
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA20245062T52101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)