1770149072 NPI number — MINDFUL AND PRESENT COUNSELING, LLC

Table of content: (NPI 1770149072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770149072 NPI number — MINDFUL AND PRESENT COUNSELING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINDFUL AND PRESENT COUNSELING, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MAP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770149072
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1305 RUSTLING OAKS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33510-2358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-455-8672
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1219 MILLENNIUM PKWY STE 116
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-3891
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-455-8672
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NORTH
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER/MANAGING MEMBER
Authorized Official Telephone Number:
813-455-8672

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 020425900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".