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General NPI Number Information
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NPI Number | 1508470428
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Entity Type | Organization
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Legal Business Name | MINDFUL SPORT AND PERFORMANCE
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Dates
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Enumeration Date | 09/08/2020
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Last Update Date | 09/08/2020
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Provider Practice Location Address
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Address Line | 401 S MAIN ST
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City | ALPHARETTA
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State | GA
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Zip | 30009-1974
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Country | US
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Telephone | 404-783-8135
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Fax |
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Provider Business Mailing Address
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Address Line | 401 S MAIN ST
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City | ALPHARETTA
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State | GA
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Zip | 30009-1974
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Country | US
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Telephone | 404-783-8135
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | SHENA F LOCKE
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Credential | LAPC
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Telephone | 404-783-8135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1800X
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Taxonomy Name | Corporate Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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