Provider Demographics
NPI:1164832192
Name:MINDFUL COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:MINDFUL COUNSELING CENTER LLC
Other - Org Name:MINDFUL COUNSELING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:609-780-3570
Mailing Address - Street 1:3069 ENGLISH CREEK AVE
Mailing Address - Street 2:SUITE 224
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-9708
Mailing Address - Country:US
Mailing Address - Phone:609-780-3570
Mailing Address - Fax:
Practice Address - Street 1:3069 ENGLISH CREEK AVE
Practice Address - Street 2:SUITE 224
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-9708
Practice Address - Country:US
Practice Address - Phone:609-780-3570
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-29
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC051820001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS81195Medicare UPIN