Provider Demographics
NPI:1629565189
Name:MIND ABOVE MATTER LLC
Entity Type:Organization
Organization Name:MIND ABOVE MATTER LLC
Other - Org Name:IMATTER OD WYATT
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-447-3001
Mailing Address - Street 1:PO BOX 1058
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76097-1058
Mailing Address - Country:US
Mailing Address - Phone:817-447-3001
Mailing Address - Fax:817-289-5623
Practice Address - Street 1:2400 E SEMINARY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76119-5502
Practice Address - Country:US
Practice Address - Phone:817-447-3001
Practice Address - Fax:817-289-5699
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIND ABOVE MATTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health