Healthcare Provider Details

I. General information

NPI: 1285119925
Provider Name (Legal Business Name): MINDSET HEALTHCARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2018
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 BRADFORD SQ STE B
FAYETTEVILLE GA
30215-1902
US

IV. Provider business mailing address

5465 HIGHWAY 42 UNIT 246
ELLENWOOD GA
30294-4042
US

V. Phone/Fax

Practice location:
  • Phone: 470-646-3738
  • Fax: 888-910-6463
Mailing address:
  • Phone: 470-646-3738
  • Fax: 888-910-6463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: OMOLOLA A OTUBAGA
Title or Position: APRN-BC/NURSE PRACTIONER
Credential:
Phone: 404-444-1904