Provider Demographics
NPI:1619485679
Name:AMAZINGLY UPLIFTED, LLC
Entity Type:Organization
Organization Name:AMAZINGLY UPLIFTED, LLC
Other - Org Name:AMAZINGLY UPLIFTED, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAFTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-588-0141
Mailing Address - Street 1:2451 CUMBERLAND PKWY SE STE 3956
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6136
Mailing Address - Country:US
Mailing Address - Phone:678-744-7045
Mailing Address - Fax:
Practice Address - Street 1:115 KENNINGHALL CT SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-3891
Practice Address - Country:US
Practice Address - Phone:678-744-7045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-11
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherIRS