Provider Demographics
NPI:1417677006
Name:MINDHOLISTICLLC
Entity Type:Organization
Organization Name:MINDHOLISTICLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:BELAGA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:800-232-5037
Mailing Address - Street 1:1501 E BROWARD BLVD APT 606
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2103
Mailing Address - Country:US
Mailing Address - Phone:954-770-0764
Mailing Address - Fax:
Practice Address - Street 1:4747 N OCEAN DR STE 214
Practice Address - Street 2:
Practice Address - City:LAUDERDALE BY THE SEA
Practice Address - State:FL
Practice Address - Zip Code:33308-2947
Practice Address - Country:US
Practice Address - Phone:800-232-5037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty