Provider Demographics
NPI:1457630634
Name:INTEGRATIVE MINDFULNESS LLC
Entity Type:Organization
Organization Name:INTEGRATIVE MINDFULNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHELEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:612-872-9231
Mailing Address - Street 1:3608 44TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-2906
Mailing Address - Country:US
Mailing Address - Phone:612-872-9231
Mailing Address - Fax:612-722-3306
Practice Address - Street 1:3608 44TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-2906
Practice Address - Country:US
Practice Address - Phone:612-872-9231
Practice Address - Fax:612-722-3306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 0499103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1255305306OtherINDIVIDUAL NPI
MN1255305306OtherINDIVIDUAL NPI