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General NPI Number Information
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NPI Number | 1225776834
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Entity Type | Organization
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Legal Business Name | MINDBODYSOUL MENTAL HEALTH & FAMILY PRACTICE LLC
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Dates
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Enumeration Date | 05/24/2022
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Last Update Date | 01/06/2025
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Provider Practice Location Address
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Address Line | 1766 LAWRENCEVILLE HWY
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City | DECATUR
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State | GA
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Zip | 30033-5641
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Country | US
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Telephone | 470-746-3142
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Fax | 404-478-8864
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Provider Business Mailing Address
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Address Line | 1766 LAWRENCEVILLE HWY
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City | DECATUR
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State | GA
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Zip | 30033-5641
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Country | US
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Telephone | 470-746-3142
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Fax | 404-478-8864
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Authorized Official
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Title or Position | NP
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Name | JUDITH FUAJONG NGULEFAC
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Credential |
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Telephone | 757-706-1776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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