Provider Demographics
NPI:1225776834
Name:MINDBODYSOUL MENTAL HEALTH & FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:MINDBODYSOUL MENTAL HEALTH & FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:FUAJONG
Authorized Official - Last Name:NGULEFAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-706-1776
Mailing Address - Street 1:1766 LAWRENCEVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-5641
Mailing Address - Country:US
Mailing Address - Phone:470-746-3142
Mailing Address - Fax:404-478-8864
Practice Address - Street 1:1766 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5641
Practice Address - Country:US
Practice Address - Phone:470-746-3142
Practice Address - Fax:404-478-8864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-24
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty