Provider Demographics
NPI:1629570304
Name:MINDFUL THERAPY PRACTICE
Entity Type:Organization
Organization Name:MINDFUL THERAPY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:IVONNE
Authorized Official - Last Name:BARSOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-893-0480
Mailing Address - Street 1:550 W VISTA WAY STE 107
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5707
Mailing Address - Country:US
Mailing Address - Phone:626-893-0480
Mailing Address - Fax:
Practice Address - Street 1:550 W VISTA WAY STE 107
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5707
Practice Address - Country:US
Practice Address - Phone:626-893-0480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64017261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4115654OtherARTICLES OF INCORPORATION