Organization
MIR BEHAVIORAL HEALTH LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MADINAH I RALSTON PHD (OWNER)
(770) 759-3444
Entity
Organization
Contact information
Practice address
6886 MAIN ST, STE 215, LITHONIA, GA 30058-4508
(404) 759-3444
Mailing address
1227 ROCKBRIDGE RD, STE 208-185, STONE MOUNTAIN, GA 30087-3064
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PSY003079
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
127231218G
—
GA
Enumeration date
09/01/2011
Last updated
09/01/2011
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