Provider Demographics
NPI:1629359807
Name:MIR BEHAVIORAL HEALTH LLC
Entity Type:Organization
Organization Name:MIR BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADINAH
Authorized Official - Middle Name:I
Authorized Official - Last Name:RALSTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-759-3444
Mailing Address - Street 1:1227 ROCKBRIDGE RD
Mailing Address - Street 2:STE 208-185
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6886 MAIN ST
Practice Address - Street 2:STE 215
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4508
Practice Address - Country:US
Practice Address - Phone:404-759-3444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003079103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA127231218GMedicaid