Healthcare Provider Details

I. General information

NPI: 1750255741
Provider Name (Legal Business Name): MINDCLUB GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2025
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1244 CLAIRMONT RD STE 101
DECATUR GA
30030-1250
US

IV. Provider business mailing address

106 MISSION CT STE 201A
FRANKLIN TN
37067-6441
US

V. Phone/Fax

Practice location:
  • Phone: 615-390-2865
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KATHY RICHARDSON
Title or Position: VP, CAO
Credential:
Phone: 615-390-2865