Healthcare Provider Details

I. General information

NPI: 1104204098
Provider Name (Legal Business Name): MENTAL EXPRESSIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 ANNE ST
GRIFFIN GA
30224-3974
US

IV. Provider business mailing address

730 ANNE ST
GRIFFIN GA
30224-3974
US

V. Phone/Fax

Practice location:
  • Phone: 770-624-9881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2050X
TaxonomyRespite Care Camp
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number State

VIII. Authorized Official

Name: AMY CRANE
Title or Position: SECRETARY
Credential:
Phone: 770-624-9881