Provider Demographics
NPI:1225130255
Name:MINTZ, ALICE D (CNS)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:D
Last Name:MINTZ
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:D
Other - Last Name:MINTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3495 PIEDMONT ROAD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1736
Mailing Address - Country:US
Mailing Address - Phone:404-364-7000
Mailing Address - Fax:
Practice Address - Street 1:200 CRESCENT CENTRE PARK
Practice Address - Street 2:DEPARTMENT OF BEHAVIORAL HEALTH
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:770-496-3609
Practice Address - Fax:770-496-3708
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN027109364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q22913Medicare UPIN
89BBBJJMedicare ID - Type Unspecified