Basic Information
| Provider Information | |||||||||
| NPI: | 1619921376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLSTAR PSYCHIATRY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WELLSTAR PSYCHIATRY, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2540 WINDY HILL RD SE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300678605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706441570 | ||||||||
| FaxNumber: | 7706441576 | ||||||||
| Practice Location | |||||||||
| Address1: | 2540 WINDY HILL RD SE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300678605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706441570 | ||||||||
| FaxNumber: | 7706441576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 06/07/2010 | ||||||||
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| AuthorizedOfficialLastName: | ASHE | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7707925261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WELLSTAR HEALTH SYSTEM, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.