Provider Demographics
NPI:1578015889
Name:MINDFUL MATTERS WELLNESS, LLC
Entity Type:Organization
Organization Name:MINDFUL MATTERS WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNFIER
Authorized Official - Middle Name:HELEN
Authorized Official - Last Name:LAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MTC
Authorized Official - Phone:847-366-0991
Mailing Address - Street 1:2121 N CAMBRIDGE AVE
Mailing Address - Street 2:APT 304
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1000
Mailing Address - Country:US
Mailing Address - Phone:847-366-0991
Mailing Address - Fax:
Practice Address - Street 1:1845 N FARWELL AVE
Practice Address - Street 2:STE 200
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1793
Practice Address - Country:US
Practice Address - Phone:847-366-0991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-03
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12283261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy