=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144968322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDEAL MINDS BEHAVIORAL SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2022
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2090 LAWRENCEVILLE SUWANEE RD # 747
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-974-0342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2090 LAWRENCEVILLE SUWANEE RD # 747
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-974-0342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MARY OPARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-974-0342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------