Provider Demographics
NPI:1679000350
Name:A CLEAN MIND LLC
Entity Type:Organization
Organization Name:A CLEAN MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:PENNEWILL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-501-1150
Mailing Address - Street 1:1610 E WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-4354
Mailing Address - Country:US
Mailing Address - Phone:850-501-1150
Mailing Address - Fax:
Practice Address - Street 1:605 E GOVERNMENT ST
Practice Address - Street 2:#C
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-8104
Practice Address - Country:US
Practice Address - Phone:850-501-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW116081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty