Healthcare Provider Details

I. General information

NPI: 1255091815
Provider Name (Legal Business Name): MINDRISE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 PENNSYLVANIA AVE
MCDONOUGH GA
30253-8999
US

IV. Provider business mailing address

1415 HIGHWAY 85 N STE 310-446
FAYETTEVILLE GA
30214-7738
US

V. Phone/Fax

Practice location:
  • Phone: 470-593-0720
  • Fax:
Mailing address:
  • Phone: 470-593-0720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SHELLY-ANNE JOHNSON
Title or Position: OWNER/THERAPIST
Credential:
Phone: 470-593-0720