Healthcare Provider Details

I. General information

NPI: 1225776834
Provider Name (Legal Business Name): MINDBODYSOUL MENTAL HEALTH & FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1766 LAWRENCEVILLE HWY
DECATUR GA
30033-5641
US

IV. Provider business mailing address

1766 LAWRENCEVILLE HWY
DECATUR GA
30033-5641
US

V. Phone/Fax

Practice location:
  • Phone: 470-746-3142
  • Fax: 404-478-8864
Mailing address:
  • Phone: 470-746-3142
  • Fax: 404-478-8864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JUDITH FUAJONG NGULEFAC
Title or Position: NP
Credential:
Phone: 757-706-1776