Healthcare Provider Details

I. General information

NPI: 1053249227
Provider Name (Legal Business Name): MINDY NELSON LBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2026
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 CLAIRMONT RD STE 103
DECATUR GA
30033-4635
US

IV. Provider business mailing address

10015 ANDERSON RANCH RD
DESCANSO CA
91916-9734
US

V. Phone/Fax

Practice location:
  • Phone: 678-400-5040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberLBA002744
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: