Provider Demographics
NPI:1245722420
Name:REBOOT PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:REBOOT PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:704-756-5770
Mailing Address - Street 1:1111 WYNFORD CMNS SW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-3776
Mailing Address - Country:US
Mailing Address - Phone:704-756-5770
Mailing Address - Fax:
Practice Address - Street 1:1111 WYNFORD CMNS SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3776
Practice Address - Country:US
Practice Address - Phone:704-756-5770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006281261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health