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General NPI Number Information
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NPI Number | 1629359807
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Entity Type | Organization
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Legal Business Name | MIR BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 09/01/2011
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Last Update Date | 09/01/2011
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Provider Practice Location Address
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Address Line | 6886 MAIN ST STE 215
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City | LITHONIA
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State | GA
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Zip | 30058-4508
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Country | US
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Telephone | 404-759-3444
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Fax |
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Provider Business Mailing Address
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Address Line | 1227 ROCKBRIDGE RD STE 208-185
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City | STONE MOUNTAIN
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State | GA
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Zip | 30087-3064
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MADINAH I RALSTON
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Credential | PHD
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Telephone | 770-759-3444
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PSY003079
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License Number State | GA
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