Provider Demographics
NPI:1750255741
Name:MINDCLUB GEORGIA LLC
Entity type:Organization
Organization Name:MINDCLUB GEORGIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP, CAO
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-390-2865
Mailing Address - Street 1:106 MISSION CT STE 201A
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1244 CLAIRMONT RD STE 101
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1250
Practice Address - Country:US
Practice Address - Phone:615-390-2865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-02
Last Update Date:2025-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty