Provider Demographics
NPI:1790287969
Name:PLENA MIND CENTER, LLC
Entity Type:Organization
Organization Name:PLENA MIND CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEBEL-PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-562-5612
Mailing Address - Street 1:1450 TECHNY RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-5447
Mailing Address - Country:US
Mailing Address - Phone:847-562-5612
Mailing Address - Fax:847-562-5613
Practice Address - Street 1:1450 TECHNY RD
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062
Practice Address - Country:US
Practice Address - Phone:847-562-5612
Practice Address - Fax:847-562-5613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-05
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center