Provider Demographics
NPI:1730943572
Name:REDEFINED MIND CENTER FOR CHANGE LLC
Entity type:Organization
Organization Name:REDEFINED MIND CENTER FOR CHANGE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAJA
Authorized Official - Middle Name:SHANAY
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:973-380-7715
Mailing Address - Street 1:1039 VICTORIA WALK LN
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4215
Mailing Address - Country:US
Mailing Address - Phone:678-926-9848
Mailing Address - Fax:
Practice Address - Street 1:1039 VICTORIA WALK LN
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4215
Practice Address - Country:US
Practice Address - Phone:973-380-7715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health