Provider Demographics
NPI:1467119339
Name:MENDING MINDS PSYCHIATRIC SERVICE PLLC
Entity Type:Organization
Organization Name:MENDING MINDS PSYCHIATRIC SERVICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZEL
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:989-928-6616
Mailing Address - Street 1:3400 SHATTUCK RD STE 2
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-3157
Mailing Address - Country:US
Mailing Address - Phone:989-270-3979
Mailing Address - Fax:
Practice Address - Street 1:3400 SHATTUCK RD STE 2
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-3157
Practice Address - Country:US
Practice Address - Phone:989-928-6616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-26
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty