Provider Demographics
NPI:1629847660
Name:MINDDEVELOPERS COUNSELING & SUPERVISION PC
Entity Type:Organization
Organization Name:MINDDEVELOPERS COUNSELING & SUPERVISION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL THERAPIST & SUPERVISOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:RENARD
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:229-942-1318
Mailing Address - Street 1:5284 FLOYD RD SW UNIT 1308
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6113
Mailing Address - Country:US
Mailing Address - Phone:229-942-1318
Mailing Address - Fax:
Practice Address - Street 1:6750 CLEARSTREAM WAY
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168-6719
Practice Address - Country:US
Practice Address - Phone:229-942-1318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty