Provider Demographics
NPI:1083185797
Name:MINDFUL LOTUS
Entity Type:Organization
Organization Name:MINDFUL LOTUS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-650-0625
Mailing Address - Street 1:49 CUMMINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ME
Mailing Address - Zip Code:04093-3336
Mailing Address - Country:US
Mailing Address - Phone:207-650-0625
Mailing Address - Fax:
Practice Address - Street 1:49 CUMMINGS AVE
Practice Address - Street 2:
Practice Address - City:BUXTON
Practice Address - State:ME
Practice Address - Zip Code:04093-3336
Practice Address - Country:US
Practice Address - Phone:207-650-0625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1376736579Medicaid