Provider Demographics
NPI:1689111379
Name:MINDFULLY WHOLE PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:MINDFULLY WHOLE PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:MANZER
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:417-413-4991
Mailing Address - Street 1:4057 W ILDEREEN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-1063
Mailing Address - Country:US
Mailing Address - Phone:417-413-4991
Mailing Address - Fax:417-719-7995
Practice Address - Street 1:4057 W ILDEREEN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-1063
Practice Address - Country:US
Practice Address - Phone:417-413-4991
Practice Address - Fax:417-719-7995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016005653261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health