Healthcare Provider Details

I. General information

NPI: 1154130300
Provider Name (Legal Business Name): AWAKEN MIND THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3295 RIVER EXCHANGE DR STE 512
NORCROSS GA
30092-4216
US

IV. Provider business mailing address

3295 RIVER EXCHANGE DR STE 512
NORCROSS GA
30092-4216
US

V. Phone/Fax

Practice location:
  • Phone: 678-778-9866
  • Fax:
Mailing address:
  • Phone: 678-778-9866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LASHUNDRA VINES
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential:
Phone: 678-778-9866