Healthcare Provider Details

I. General information

NPI: 1902968910
Provider Name (Legal Business Name): MRS. AMANDA MILLWOOD MULLINAX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977A TAYLOR ST SW
CONYERS GA
30012-5357
US

IV. Provider business mailing address

977A TAYLOR ST SW
CONYERS GA
30012-5357
US

V. Phone/Fax

Practice location:
  • Phone: 770-918-6677
  • Fax: 770-918-6686
Mailing address:
  • Phone: 770-918-6677
  • Fax: 770-918-6686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: