Provider Demographics
NPI:1871001057
Name:MENDING WINGS TO SOAR
Entity Type:Organization
Organization Name:MENDING WINGS TO SOAR
Other - Org Name:MENDING WINGS TO SOAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHISON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:973-937-8632
Mailing Address - Street 1:460 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3582
Mailing Address - Country:US
Mailing Address - Phone:973-937-8632
Mailing Address - Fax:
Practice Address - Street 1:460 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3582
Practice Address - Country:US
Practice Address - Phone:973-937-8632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00559100261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)