Healthcare Provider Details

I. General information

NPI: 1538025028
Provider Name (Legal Business Name): MENTALEASE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2025
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1248 FLINT RD
FORSYTH GA
31029-6823
US

IV. Provider business mailing address

1248 FLINT RD
FORSYTH GA
31029-6823
US

V. Phone/Fax

Practice location:
  • Phone: 478-960-2887
  • Fax: 478-960-2887
Mailing address:
  • Phone: 478-960-2887
  • Fax: 478-960-2887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANGELA QUEEN
Title or Position: OWNER
Credential:
Phone: 478-960-2887