MEDICARE: MINDSCAPE WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1841146156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDSCAPE WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	7574 HIGHWAY 85
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-3447
Country	:	US
Telephone Number	:	470-746-9304
Fax Number	:

Provider Business Practice Location Address
First Line	:	7574 HIGHWAY 85
Second Line	:
City	:	RIVERDALE
State	:	GA
Zip	:	30274-3447
Country	:	US
Telephone Number	:	470-746-9394
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	OBIAGELI GLORIA MONEKE
Credential	:	PMHNP
Telephone Number	:	470-746-9304

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	05/21/2026

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