| Organization Name: | WELLSTAR PEDIATRIC & FAMILY WELLNESS CENTER, LLC |
| NPI Number: | 1073742482 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | NICOLE ASHE (ASST; VP OF FINANCE) |
| Mailing Address: | 1810 Mulkey Rd Suite 201 Austell |
| State: | GA US |
| Postal Code: | 301061151 |
| Phone Number: | 7706342349 |
| Fax Number: | 7708190597 |
| NPI Enumeration Date: | 07/07/2009 |
| NPI Last Update Date: | 07/07/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TC0700X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | |