Provider Demographics
NPI:1871210260
Name:MINDFUL MENTALITY, LLC
Entity type:Organization
Organization Name:MINDFUL MENTALITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:NORTHINGTON-REISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, QBA
Authorized Official - Phone:630-926-0577
Mailing Address - Street 1:1204 STONE MEADOWS CT
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5943
Mailing Address - Country:US
Mailing Address - Phone:630-926-0577
Mailing Address - Fax:
Practice Address - Street 1:3633 WHEELER RD STE 320
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6552
Practice Address - Country:US
Practice Address - Phone:068-423-2797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1346811775OtherNPI
GA1457632150OtherNPI
GA15488319602OtherNPI
GA1528639952OtherNPI