Organization
PROVENANCE PSYCHIATRIC SERVICES LLC
Active
Other names
Provenance Psychiatry
Organization subpart
No
Provider details
NPI number
Authorized official
BRIAN KENT JOHNSON APRN (OWNER)
(610) 453-1548
Entity
Organization
Contact information
Practice address
643 RAY LEWIS RD, BLAIRSVILLE, GA 30512-1439
(706) 970-1948
(877) 930-7732
Mailing address
643 RAY LEWIS RD, BLAIRSVILLE, GA 30512-1439
(706) 970-1948
(877) 930-7732
Taxonomy
Speciality
Code
Description
License number
State
364SP0808X
Psychiatric/Mental Health Clinical Nurse Specialist
Primary
—
—
Other
Enumeration date
06/27/2023
Last updated
03/19/2025
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