Healthcare Provider Details

I. General information

NPI: 1871210260
Provider Name (Legal Business Name): MINDFUL MENTALITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD STE 320
AUGUSTA GA
30909-6552
US

IV. Provider business mailing address

1204 STONE MEADOWS CT
GROVETOWN GA
30813-5943
US

V. Phone/Fax

Practice location:
  • Phone: 68-423-2797
  • Fax:
Mailing address:
  • Phone: 630-926-0577
  • 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 Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE ANNE NORTHINGTON-REISSMAN
Title or Position: OWNER AND PSYCHOLOGIST
Credential: PHD, QBA
Phone: 630-926-0577