Provider Demographics
NPI:1639691116
Name:MIND CONNECTIONS
Entity Type:Organization
Organization Name:MIND CONNECTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:YOUNGLOVE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LLP
Authorized Official - Phone:517-513-7178
Mailing Address - Street 1:225 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:MI
Mailing Address - Zip Code:49247-1001
Mailing Address - Country:US
Mailing Address - Phone:517-260-3431
Mailing Address - Fax:
Practice Address - Street 1:225 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:MI
Practice Address - Zip Code:49247-1001
Practice Address - Country:US
Practice Address - Phone:517-260-3431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011293101YP2500X
MI6301013012103TC0700X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0200210Medicaid