Provider Demographics
NPI:1700244134
Name:MASTERMIND COUNSELING SERVICES
Entity Type:Organization
Organization Name:MASTERMIND COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:II
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-858-3172
Mailing Address - Street 1:2077 RAINTREE PL
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7956
Mailing Address - Country:US
Mailing Address - Phone:678-858-3172
Mailing Address - Fax:
Practice Address - Street 1:2077 RAINTREE PL
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7956
Practice Address - Country:US
Practice Address - Phone:678-858-3172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007172251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health