Provider Demographics
NPI:1851164644
Name:HEALTHY MINDS WELLNESS GROUP, PLLC
Entity Type:Organization
Organization Name:HEALTHY MINDS WELLNESS GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAOLA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KASENETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-607-4289
Mailing Address - Street 1:10519 BERMUDA ISLE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2721
Mailing Address - Country:US
Mailing Address - Phone:813-607-4289
Mailing Address - Fax:813-291-7529
Practice Address - Street 1:10025 W HILLSBOROUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3000
Practice Address - Country:US
Practice Address - Phone:813-607-4289
Practice Address - Fax:813-291-7529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHY MINDS WELLNESS GROUP, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119486300Medicaid