Provider Demographics
NPI:1851972814
Name:MINDFUL PERFORMANCE THERAPY, PLLC
Entity Type:Organization
Organization Name:MINDFUL PERFORMANCE THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLANT
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LLP
Authorized Official - Phone:989-370-0703
Mailing Address - Street 1:1414 TRADE CENTER DR STE 26-E
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-8944
Mailing Address - Country:US
Mailing Address - Phone:989-370-0703
Mailing Address - Fax:
Practice Address - Street 1:1414 TRADE CENTER DR STE 26-E
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49696-8944
Practice Address - Country:US
Practice Address - Phone:989-370-0703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty