Provider Demographics
NPI:1538856398
Name:EXTRAORDINARY MINDS
Entity type:Organization
Organization Name:EXTRAORDINARY MINDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-446-5360
Mailing Address - Street 1:15 ROBERTS WAY SE
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-6873
Mailing Address - Country:US
Mailing Address - Phone:470-446-5360
Mailing Address - Fax:
Practice Address - Street 1:532 OLD MARLTON PIKE W
Practice Address - Street 2:SUITE 510
Practice Address - City:EVESHAM
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-242-2121
Practice Address - Fax:856-242-2121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty