Provider Demographics
NPI:1376858100
Name:GROW HEAL LIVE LEAD LLC
Entity Type:Organization
Organization Name:GROW HEAL LIVE LEAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:678-463-1092
Mailing Address - Street 1:2964 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 760
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2153
Mailing Address - Country:US
Mailing Address - Phone:678-463-1092
Mailing Address - Fax:
Practice Address - Street 1:2964 PEACHTREE RD NW
Practice Address - Street 2:SUITE 760
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2153
Practice Address - Country:US
Practice Address - Phone:678-463-1092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3256103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty