Organization
MEDICAL GROUP CONSULTANT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HOLLY MIMS LPC (CLINICAL DIRECTOR)
(410) 905-5678
Entity
Organization
Contact information
Practice address
6337 HIGHWAY 42, SUITE 3, REX, GA 30273-1651
(404) 895-5510
Mailing address
6337 HIGHWAY 42, SUITE 3, REX, GA 30273-1651
(404) 895-5510
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
LPC5081
GA
101YM0800X
Mental Health Counselor
LPC5081
GA
101YP2500X
Professional Counselor
Primary
LPC5081
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003127731A
—
GA
Enumeration date
12/15/2012
Last updated
12/15/2012
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