Provider Demographics
NPI:1295480648
Name:WHOLE MIND & HEART PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:WHOLE MIND & HEART PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MADDIE
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:ODEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-632-3847
Mailing Address - Street 1:1000 ARBOR WAY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-8715
Mailing Address - Country:US
Mailing Address - Phone:678-632-3847
Mailing Address - Fax:678-696-7971
Practice Address - Street 1:123 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5092
Practice Address - Country:US
Practice Address - Phone:678-632-3847
Practice Address - Fax:678-696-7971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW007546OtherSTATE LICENSE