Healthcare Provider Details

I. General information

NPI: 1699408005
Provider Name (Legal Business Name): GROWTH MINDSET WELLNESS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2022
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CORPORATE CENTER DR STE B
STOCKBRIDGE GA
30281-7382
US

IV. Provider business mailing address

175 CORPORATE CENTER DR STE B
STOCKBRIDGE GA
30281-7382
US

V. Phone/Fax

Practice location:
  • Phone: 470-275-2358
  • Fax:
Mailing address:
  • Phone: 470-275-2358
  • Fax: 470-319-6353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. TIFFANY BATES
Title or Position: OWNER
Credential: APRN
Phone: 470-275-2358