Healthcare Provider Details

I. General information

NPI: 1669974887
Provider Name (Legal Business Name): CREATIVE MINDS FOR WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 03/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LEE BYRD RD
LOGANVILLE GA
30052-2310
US

IV. Provider business mailing address

4160 LOGAN DR UNIT 3261
LOGANVILLE GA
30052-9531
US

V. Phone/Fax

Practice location:
  • Phone: 770-599-7512
  • Fax:
Mailing address:
  • Phone: 770-599-7512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberCSW004354
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MANDY MICHELLE MILLER
Title or Position: COO
Credential: LCSW
Phone: 912-200-7608