1992379234 NPI number — MINDWORKS MENTAL HEALTH

Table of content: (NPI 1992379234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992379234 NPI number — MINDWORKS MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MINDWORKS MENTAL HEALTH
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:
1992379234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3303 S PINE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61802-7130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-721-3263
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
328 N. NEIL. ST, SUIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHAMPAIGN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61820-3949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-722-6336
Provider Business Practice Location Address Fax Number:
217-354-9107
Provider Enumeration Date:
05/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PEREGUD-AKSIMENTYEVA
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL THERAPIST
Authorized Official Telephone Number:
217-721-3263

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33602 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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