Provider Demographics
NPI:1134671910
Name:MINDFUL LIFE COUNSELING CENTER PLLC
Entity Type:Organization
Organization Name:MINDFUL LIFE COUNSELING CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MS ED, LCPC, LDN
Authorized Official - Phone:815-751-7700
Mailing Address - Street 1:15632 HWY 110 S.
Mailing Address - Street 2:SUITE 26
Mailing Address - City:WHITEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75791
Mailing Address - Country:US
Mailing Address - Phone:815-751-7700
Mailing Address - Fax:190-329-7699
Practice Address - Street 1:15632 ST HWY 110 S
Practice Address - Street 2:SUITE 26
Practice Address - City:WHITEHOUSE
Practice Address - State:TX
Practice Address - Zip Code:75791-9384
Practice Address - Country:US
Practice Address - Phone:815-751-7700
Practice Address - Fax:190-329-7699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX76385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty