MEDICARE: MIND RESTORATION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1619753274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND RESTORATION, LLC

Provider Business Mailing Address
First Line	:	3545 BROAD ST UNIT 660156
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30366-2123
Country	:	US
Telephone Number	:	404-275-4604
Fax Number	:

Provider Business Practice Location Address
First Line	:	3545 BROAD ST UNIT 660156
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30366-2123
Country	:	US
Telephone Number	:	404-275-4604
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	DR. ADAM MCTIGHE
Credential	:
Telephone Number	:	412-951-2483

Provider Enumeration Date	:	09/07/2023
Last Update Date	:	09/07/2023

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Directions to “MIND RESTORATION, LLC ” Practice Location

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