Provider Demographics
NPI:1598242893
Name:WIDE MIND WELLNESS, LLC
Entity Type:Organization
Organization Name:WIDE MIND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:LATEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-520-5749
Mailing Address - Street 1:11058 S SUNUP WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84009-7720
Mailing Address - Country:US
Mailing Address - Phone:801-520-5749
Mailing Address - Fax:
Practice Address - Street 1:11058 S SUNUP WAY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84009-7720
Practice Address - Country:US
Practice Address - Phone:801-520-5749
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-19
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty