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General NPI Number Information
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NPI Number | 1538856398
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Entity Type | Organization
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Legal Business Name | EXTRAORDINARY MINDS
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Dates
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Enumeration Date | 04/21/2023
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Last Update Date | 04/21/2023
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Provider Practice Location Address
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Address Line | 532 OLD MARLTON PIKE W SUITE 510
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City | EVESHAM
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State | NJ
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Zip | 08053
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Country | US
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Telephone | 856-242-2121
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Fax | 856-242-2121
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Provider Business Mailing Address
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Address Line | 15 ROBERTS WAY SE
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City | ACWORTH
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State | GA
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Zip | 30102-6873
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Country | US
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Telephone | 470-446-5360
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING
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Name | KAREN WALLACE
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Credential |
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Telephone | 470-446-5360
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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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