=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295480648
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLE MIND & HEART PSYCHOTHERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2022
-----------------------------------------------------
Last Update Date | 02/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 123 EAGLES LANDING PKWY
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-5092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-632-3847
-----------------------------------------------------
Fax | 678-696-7971
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1000 ARBOR WAY
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-8715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-632-3847
-----------------------------------------------------
Fax | 678-696-7971
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MADDIE MELISSA ODEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 678-632-3847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------