Provider Demographics
NPI:1437657301
Name:MENDING HEARTS MENDING MINDS INC
Entity Type:Organization
Organization Name:MENDING HEARTS MENDING MINDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:916-960-7795
Mailing Address - Street 1:1500 W EL CAMINO AVENUE #464
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-9756
Mailing Address - Country:US
Mailing Address - Phone:916-960-7795
Mailing Address - Fax:
Practice Address - Street 1:6524 44TH STREET
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5667
Practice Address - Country:US
Practice Address - Phone:916-960-7795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF83840251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health