Provider Demographics
NPI:1083493761
Name:STATE OF MIND THERAPY SERVICES, LLC
Entity Type:Organization
Organization Name:STATE OF MIND THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:KILROY
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:219-230-8311
Mailing Address - Street 1:709 PLAZA DR., SUITE 2 PMB 279
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-1572
Mailing Address - Country:US
Mailing Address - Phone:219-230-8311
Mailing Address - Fax:
Practice Address - Street 1:55 SHORE DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-1008
Practice Address - Country:US
Practice Address - Phone:219-230-8311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-22
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty