Provider Demographics
NPI:1639582661
Name:MINDFUL CONNECTIONS, LLC
Entity Type:Organization
Organization Name:MINDFUL CONNECTIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:GALLOSO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CAP, ACHT
Authorized Official - Phone:954-770-2363
Mailing Address - Street 1:733 NW 30TH CT
Mailing Address - Street 2:UNIT # 7
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-2400
Mailing Address - Country:US
Mailing Address - Phone:954-770-2363
Mailing Address - Fax:
Practice Address - Street 1:3042 N FEDERAL HWY
Practice Address - Street 2:SUITE 207
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1400
Practice Address - Country:US
Practice Address - Phone:954-770-2363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW8346261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010912100Medicaid