Provider Demographics
NPI:1275741639
Name:MIRROR IMAGE GROUP, LLC
Entity type:Organization
Organization Name:MIRROR IMAGE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-452-7752
Mailing Address - Street 1:285 S PERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4840
Mailing Address - Country:US
Mailing Address - Phone:404-452-7752
Mailing Address - Fax:
Practice Address - Street 1:285 S PERRY ST
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4840
Practice Address - Country:US
Practice Address - Phone:404-452-7752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC000985101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty