Provider Demographics
NPI:1598589467
Name:MINTZE, SHEMAR LEMONT
Entity type:Individual
Prefix:
First Name:SHEMAR
Middle Name:LEMONT
Last Name:MINTZE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 MARTIN LUTHER KING JR DR SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-2160
Mailing Address - Country:US
Mailing Address - Phone:912-292-3214
Mailing Address - Fax:
Practice Address - Street 1:290 MARTIN LUTHER KING JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-2160
Practice Address - Country:US
Practice Address - Phone:912-292-3214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB1093528106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician