Provider Demographics
NPI:1477222040
Name:FORESIGHT MENTAL HEALTH GROUP PLLC
Entity Type:Organization
Organization Name:FORESIGHT MENTAL HEALTH GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUCINO MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-588-8995
Mailing Address - Street 1:PO BOX 530077
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0077
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:465 WINN WAY STE 221
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1723
Practice Address - Country:US
Practice Address - Phone:888-588-8995
Practice Address - Fax:510-756-0812
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FORESIGHT MENTAL HEALTH GROUP PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-08
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty