Provider Demographics
NPI:1003234774
Name:MINDFULLY RECONNECT LLC
Entity Type:Organization
Organization Name:MINDFULLY RECONNECT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SCHROLL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:307-634-6883
Mailing Address - Street 1:1001 W 31ST ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2442
Mailing Address - Country:US
Mailing Address - Phone:307-634-6883
Mailing Address - Fax:307-634-9462
Practice Address - Street 1:1001 W 31ST ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2442
Practice Address - Country:US
Practice Address - Phone:307-634-6883
Practice Address - Fax:307-634-9462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLCSW 731251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY106079100Medicaid