=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811537558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL THERAPY WORKS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2020
-----------------------------------------------------
Last Update Date | 01/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2900 PACES FERRY RD SE STE C2000
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-5730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-862-1735
-----------------------------------------------------
Fax | 470-235-4663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 PACES FERRY RD SE STE C2000
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-5730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-862-1735
-----------------------------------------------------
Fax | 470-235-4663
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LCSW
-----------------------------------------------------
Name | STEPHANIE NICHOLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-862-1735
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------