Provider Demographics
NPI:1578235826
Name:MINDFUL BEHAVIORAL HEALTHCARE, LLC
Entity Type:Organization
Organization Name:MINDFUL BEHAVIORAL HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISSIGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-328-9139
Mailing Address - Street 1:717 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4580
Mailing Address - Country:US
Mailing Address - Phone:407-846-0533
Mailing Address - Fax:407-518-1730
Practice Address - Street 1:717 E OAK ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4580
Practice Address - Country:US
Practice Address - Phone:407-846-0533
Practice Address - Fax:407-518-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-04
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006520800Medicaid