Provider Demographics
NPI:1962678540
Name:MINTFOUR CHANGE, LLC
Entity Type:Organization
Organization Name:MINTFOUR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:MINTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LPC
Authorized Official - Phone:678-526-1132
Mailing Address - Street 1:6886 MAIN ST STE 215
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-4508
Mailing Address - Country:US
Mailing Address - Phone:678-526-1132
Mailing Address - Fax:678-526-1153
Practice Address - Street 1:6886 MAIN ST STE 215
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4508
Practice Address - Country:US
Practice Address - Phone:678-526-1132
Practice Address - Fax:678-526-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004278101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty