Organization
EXTRAORDINARY MINDS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KAREN WALLACE (CREDENTIALING)
(470) 446-5360
Entity
Organization
Contact information
Practice address
532 OLD MARLTON PIKE W, SUITE 510, EVESHAM, NJ 08053
(856) 242-2121
(856) 242-2121
Mailing address
15 ROBERTS WAY SE, ACWORTH, GA 30102-6873
(470) 446-5360
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Enumeration date
04/21/2023
Last updated
04/21/2023
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