Provider Demographics
NPI:1790542611
Name:MYNDFIT MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:MYNDFIT MENTAL HEALTH, LLC
Other - Org Name:MYNDFIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:FAIRLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:QMHP-CS
Authorized Official - Phone:210-665-3330
Mailing Address - Street 1:13423 CORAM PEAK ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78248-1201
Mailing Address - Country:US
Mailing Address - Phone:210-665-3330
Mailing Address - Fax:
Practice Address - Street 1:13423 CORAM PEAK ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78248-1201
Practice Address - Country:US
Practice Address - Phone:210-665-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities