Provider Demographics
NPI:1033683495
Name:HEART TREE LLC
Entity type:Organization
Organization Name:HEART TREE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANNAH
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOODELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-375-4448
Mailing Address - Street 1:300 COLONIAL CENTER PKWY STE 100N
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4892
Mailing Address - Country:US
Mailing Address - Phone:404-375-4448
Mailing Address - Fax:
Practice Address - Street 1:315 W PONCE DE LEON AVE STE 480
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2489
Practice Address - Country:US
Practice Address - Phone:404-375-4448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW4122OtherLICENSE