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General NPI Number Information
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NPI Number | 1700680394
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Entity Type | Organization
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Legal Business Name | MADEMIND WELLNESS & PERFORMANCE
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Dates
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Enumeration Date | 04/02/2025
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 3402 CHESTERFIELD CT
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City | SNELLVILLE
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State | GA
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Zip | 30039-4609
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Country | US
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Telephone | 206-734-0964
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Fax |
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Provider Business Mailing Address
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Address Line | 7234 W NORTH AVE STE 208
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City | CHICAGO
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State | IL
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Zip | 60707-4202
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Country | US
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Telephone | 206-734-0964
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL WILEY JR.
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Credential | LCPC
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Telephone | 206-734-0964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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