Provider Demographics
NPI:1508470428
Name:MINDFUL SPORT AND PERFORMANCE
Entity Type:Organization
Organization Name:MINDFUL SPORT AND PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHENA
Authorized Official - Middle Name:F
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:LAPC
Authorized Official - Phone:404-783-8135
Mailing Address - Street 1:401 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1974
Mailing Address - Country:US
Mailing Address - Phone:404-783-8135
Mailing Address - Fax:
Practice Address - Street 1:401 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1974
Practice Address - Country:US
Practice Address - Phone:404-783-8135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty