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General NPI Number Information
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NPI Number | 1669974887
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Entity Type | Organization
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Legal Business Name | CREATIVE MINDS FOR WELLNESS, LLC
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Dates
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Enumeration Date | 03/03/2018
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Last Update Date | 03/03/2018
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Provider Practice Location Address
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Address Line | 125 LEE BYRD RD
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City | LOGANVILLE
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State | GA
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Zip | 30052-2310
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Country | US
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Telephone | 770-599-7512
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Fax |
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Provider Business Mailing Address
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Address Line | 4160 LOGAN DR UNIT 3261
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City | LOGANVILLE
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State | GA
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Zip | 30052-9531
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Country | US
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Telephone | 770-599-7512
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Fax |
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Authorized Official
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Title or Position | COO
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Name | MANDY MICHELLE MILLER
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Credential | LCSW
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Telephone | 912-200-7608
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | CSW004354
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health 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 | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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