Healthcare Provider Details

I. General information

NPI: 1114838513
Provider Name (Legal Business Name): MIXED WORKD THERAPY GA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1564 AIRLINE RD
MCDONOUGH GA
30252-2684
US

IV. Provider business mailing address

1564 AIRLINE RD
MCDONOUGH GA
30252-2684
US

V. Phone/Fax

Practice location:
  • Phone: 404-819-6889
  • Fax:
Mailing address:
  • Phone: 404-819-6889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTEN MCDONALD
Title or Position: FOUNDING CLINICAL DIRECTOR
Credential: PHD
Phone: 404-819-6889