Provider Demographics
NPI:1346732765
Name:MINDFUL HEALING LLC
Entity Type:Organization
Organization Name:MINDFUL HEALING LLC
Other - Org Name:SOUTHWICK INTEGRATIVE HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHWICK
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:801-432-7712
Mailing Address - Street 1:8541 S REDWOOD RD STE C2
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-9323
Mailing Address - Country:US
Mailing Address - Phone:801-432-7712
Mailing Address - Fax:
Practice Address - Street 1:8541 S REDWOOD RD STE C2
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088
Practice Address - Country:US
Practice Address - Phone:801-432-7712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-01
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT200020-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1017129Medicaid