=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063394856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIRRORS OF THE HEART INDEPENDENT LIVING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2025
-----------------------------------------------------
Last Update Date | 07/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4316 RIVERWOOD CIR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30035-2929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 669-226-0381
-----------------------------------------------------
Fax | 559-408-5589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4316 RIVERWOOD CIR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30035-2929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 669-226-0381
-----------------------------------------------------
Fax | 559-408-5589
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CASE MANAGER/OWNER
-----------------------------------------------------
Name | LIVIA S BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 669-226-0381
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------