Provider Demographics
NPI:1558843813
Name:MINDOULA HEALTH INC.
Entity Type:Organization
Organization Name:MINDOULA HEALTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SVP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:COUTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-650-2802
Mailing Address - Street 1:8040 GEORGIA AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8040 GEORGIA AVE STE 170
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-4959
Practice Address - Country:US
Practice Address - Phone:888-879-9786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-04
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251S00000X
MD251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250004132Medicaid
MD951032000Medicaid
NC1558843813Medicaid