Provider Demographics
NPI:1679336077
Name:KINTSUGI MENTAL HEALTH LLC
Entity Type:Organization
Organization Name:KINTSUGI MENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:LAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LP
Authorized Official - Phone:781-698-9171
Mailing Address - Street 1:5902 TOLMAN TER
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-3360
Mailing Address - Country:US
Mailing Address - Phone:781-698-9171
Mailing Address - Fax:
Practice Address - Street 1:119 MARTIN LUTHER KING JR BLVD STE LL-20
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-3355
Practice Address - Country:US
Practice Address - Phone:608-291-3586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-30
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty