Provider Demographics
NPI:1174184311
Name:MIND HEALING THERAPEUTIC SERVICES PLLC
Entity Type:Organization
Organization Name:MIND HEALING THERAPEUTIC SERVICES PLLC
Other - Org Name:MIND HEALING THERAPEUTIC SERVICES PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MANESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-844-5322
Mailing Address - Street 1:4425 GRAY WOLF WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8260
Mailing Address - Country:US
Mailing Address - Phone:336-844-5322
Mailing Address - Fax:
Practice Address - Street 1:1451 S ELM EUGENE ST # 3112
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-2200
Practice Address - Country:US
Practice Address - Phone:336-844-5322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1326414731Medicaid