Provider Demographics
NPI:1225421076
Name:MIND & BODY CHRISTIAN THERAPIST GROUP
Entity Type:Organization
Organization Name:MIND & BODY CHRISTIAN THERAPIST GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:GAMBLE
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:678-596-5385
Mailing Address - Street 1:356 TOCCOA PL
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-5493
Mailing Address - Country:US
Mailing Address - Phone:678-596-5385
Mailing Address - Fax:
Practice Address - Street 1:3007 CHEROKEE ST NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2827
Practice Address - Country:US
Practice Address - Phone:678-596-5385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008296101Y00000X
GAMT009630225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty