Provider Demographics
NPI:1376902486
Name:TWO TRAILS MENTAL HEALTH AND WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:TWO TRAILS MENTAL HEALTH AND WELLNESS CENTER, LLC
Other - Org Name:DR. DANIELLE M. MINK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MINK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:717-856-0220
Mailing Address - Street 1:560 KELLERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MC ALISTERVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17049-8580
Mailing Address - Country:US
Mailing Address - Phone:717-856-0220
Mailing Address - Fax:717-685-3242
Practice Address - Street 1:8638 ROUTE 104
Practice Address - Street 2:SUITE 10
Practice Address - City:MOUNT PLEASANT MILLS
Practice Address - State:PA
Practice Address - Zip Code:17853-8752
Practice Address - Country:US
Practice Address - Phone:717-856-0220
Practice Address - Fax:717-685-3242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016911103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA293713OtherCMS PTAN