Provider Demographics
NPI:1942795836
Name:SYCAMORE WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:SYCAMORE WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:GYNETTE
Authorized Official - Last Name:CROSS LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC, EAS-C
Authorized Official - Phone:404-503-0701
Mailing Address - Street 1:5400 LAWRENCEVILLE HWY NW STE E3
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-5956
Mailing Address - Country:US
Mailing Address - Phone:404-503-0701
Mailing Address - Fax:404-537-1947
Practice Address - Street 1:5400 LAWRENCEVILLE HWY NW STE E3
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-5956
Practice Address - Country:US
Practice Address - Phone:404-503-0701
Practice Address - Fax:404-537-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004217251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA501854029AMedicaid