Provider Demographics
NPI:1235646134
Name:FAMILY CENTER FOR MINDFULNESS AND RESILIENCY
Entity Type:Organization
Organization Name:FAMILY CENTER FOR MINDFULNESS AND RESILIENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERDORFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-983-1766
Mailing Address - Street 1:1444 WILTSHIRE CIR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-1364
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:848 HIRAM ACWORTH HWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2286
Practice Address - Country:US
Practice Address - Phone:404-769-3084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006329101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107804BMedicaid
GA1316246044OtherINDIVIDUAL NPI
GALPC006329OtherGA STATE LICENSE