Provider Demographics
NPI:1205471695
Name:MINDBRAIN INSTITUTE OF ATLANTA
Entity type:Organization
Organization Name:MINDBRAIN INSTITUTE OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:HOLBERG
Authorized Official - Last Name:GORDICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:404-692-7027
Mailing Address - Street 1:2200 CENTURY PKWY NE STE 200
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3103
Mailing Address - Country:US
Mailing Address - Phone:404-692-7027
Mailing Address - Fax:
Practice Address - Street 1:2200 CENTURY PKWY NE STE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3103
Practice Address - Country:US
Practice Address - Phone:404-692-7027
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1356672331OtherNPI 1