Provider Demographics
NPI:1376162487
Name:MINDFULLY ALIVE, LLC
Entity Type:Organization
Organization Name:MINDFULLY ALIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:R
Authorized Official - Last Name:NYERGES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:201-308-3987
Mailing Address - Street 1:18 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:HO HO KUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07423-1582
Mailing Address - Country:US
Mailing Address - Phone:201-308-3097
Mailing Address - Fax:
Practice Address - Street 1:18 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:HO HO KUS
Practice Address - State:NJ
Practice Address - Zip Code:07423-1582
Practice Address - Country:US
Practice Address - Phone:201-208-3987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty