1467720565 NPI number — MINDMENDER COUNSELING SERVICES, PLLC

Table of content: (NPI 1467720565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467720565 NPI number — MINDMENDER COUNSELING SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINDMENDER COUNSELING SERVICES, PLLC
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:
Provider Other Organization Name Type Code:
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:
1467720565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2067
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORNELIUS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28031-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19824 W CATAWBA AVE
Provider Second Line Business Practice Location Address:
SUITE G-205
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28031-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-892-1828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2011

Additional Information

Authorized Official

Authorized Official Last Name:
SERRENO
Authorized Official First Name:
COLLEEN
Authorized Official Middle Name:
MARY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-892-1828

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  3977 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YA0400X , with the licence number: 1132 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 56162 . This is a "MEDCOST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6102349 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2056553 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 130WW . This is a "BLUE CROSS BLUE SHIELD OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 369641 . This is a "UNITED BEHAVIORAL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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