Provider Demographics
NPI:1346586567
Name:MEDICAL GROUP CONSULTANT LLC
Entity Type:Organization
Organization Name:MEDICAL GROUP CONSULTANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:410-905-5678
Mailing Address - Street 1:6337 HIGHWAY 42
Mailing Address - Street 2:SUITE 3
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-1651
Mailing Address - Country:US
Mailing Address - Phone:404-895-5510
Mailing Address - Fax:
Practice Address - Street 1:6337 HIGHWAY 42
Practice Address - Street 2:SUITE 3
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-1651
Practice Address - Country:US
Practice Address - Phone:404-895-5510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-15
Last Update Date:2012-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC5081101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127731AMedicaid