Provider Demographics
NPI:1376199356
Name:MANDALA COUNSELING SERVICES LLC
Entity Type:Organization
Organization Name:MANDALA COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:AUSTEN
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:224-545-1225
Mailing Address - Street 1:339 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-2331
Mailing Address - Country:US
Mailing Address - Phone:224-545-1225
Mailing Address - Fax:
Practice Address - Street 1:8600 NORTHWEST HWY # 14
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012-2706
Practice Address - Country:US
Practice Address - Phone:224-545-1225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)