Healthcare Provider Details

I. General information

NPI: 1144968322
Provider Name (Legal Business Name): IDEAL MINDS BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2090 LAWRENCEVILLE SUWANEE RD # 747
SUWANEE GA
30024-2600
US

IV. Provider business mailing address

2090 LAWRENCEVILLE SUWANEE RD # 747
SUWANEE GA
30024-2600
US

V. Phone/Fax

Practice location:
  • Phone: 678-974-0342
  • Fax:
Mailing address:
  • Phone: 678-974-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARY OPARA
Title or Position: CEO/AUTHORIZED OFFICIAL
Credential:
Phone: 678-974-0342