Healthcare Provider Details

I. General information

NPI: 1508470428
Provider Name (Legal Business Name): MINDFUL SPORT AND PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S MAIN ST
ALPHARETTA GA
30009-1974
US

IV. Provider business mailing address

401 S MAIN ST
ALPHARETTA GA
30009-1974
US

V. Phone/Fax

Practice location:
  • Phone: 404-783-8135
  • Fax:
Mailing address:
  • Phone: 404-783-8135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: SHENA F LOCKE
Title or Position: CEO
Credential: LAPC
Phone: 404-783-8135