Provider Demographics
NPI:1972263218
Name:AUTHENTIC LIFE WELLNESS
Entity Type:Organization
Organization Name:AUTHENTIC LIFE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-296-4133
Mailing Address - Street 1:771 LINDBERGH DR NE APT 2102
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-3638
Mailing Address - Country:US
Mailing Address - Phone:678-296-4133
Mailing Address - Fax:
Practice Address - Street 1:67 PEACHTREE PARK DR NE STE 102
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1318
Practice Address - Country:US
Practice Address - Phone:470-298-6589
Practice Address - Fax:404-921-9251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty