Healthcare Provider Details

I. General information

NPI: 1316732522
Provider Name (Legal Business Name): BALANCED MIND BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LANIER AVE W STE 200
FAYETTEVILLE GA
30214-7443
US

IV. Provider business mailing address

320 LANIER AVE W STE 200
FAYETTEVILLE GA
30214-7443
US

V. Phone/Fax

Practice location:
  • Phone: 470-516-4399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PRISCILLA MAXWELL
Title or Position: OWNER
Credential:
Phone: 470-516-4399