Provider Demographics
NPI:1497229421
Name:MINDBRIDGE GROUP, LLC
Entity Type:Organization
Organization Name:MINDBRIDGE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCEACHIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:917-576-0305
Mailing Address - Street 1:5130 DERBY RD
Mailing Address - Street 2:
Mailing Address - City:TOBYHANNA
Mailing Address - State:PA
Mailing Address - Zip Code:18466-8212
Mailing Address - Country:US
Mailing Address - Phone:917-576-0305
Mailing Address - Fax:
Practice Address - Street 1:5520 MUNICIPAL DR BSMT
Practice Address - Street 2:
Practice Address - City:TOBYHANNA
Practice Address - State:PA
Practice Address - Zip Code:18466-7714
Practice Address - Country:US
Practice Address - Phone:917-576-0305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-12
Last Update Date:2019-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1346674975OtherMICHELLE BACKUS