Provider Demographics
NPI:1467980300
Name:MINDFUL THERAPY, LLC
Entity Type:Organization
Organization Name:MINDFUL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WENDT
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LMSW, CAADC
Authorized Official - Phone:989-388-4185
Mailing Address - Street 1:122 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1024
Mailing Address - Country:US
Mailing Address - Phone:989-388-4185
Mailing Address - Fax:989-388-4187
Practice Address - Street 1:122 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1024
Practice Address - Country:US
Practice Address - Phone:989-388-4185
Practice Address - Fax:989-388-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0290035101YA0400X, 101YM0800X, 171M00000X
MISA0190019101YA0400X, 101YM0800X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty