Provider Demographics
NPI:1891108320
Name:MINDFUL BEHAVIORAL
Entity Type:Organization
Organization Name:MINDFUL BEHAVIORAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOMOYATTA
Authorized Official - Middle Name:AKILA
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-697-0767
Mailing Address - Street 1:3255 LANDMARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-8461
Mailing Address - Country:US
Mailing Address - Phone:843-864-1661
Mailing Address - Fax:843-628-1020
Practice Address - Street 1:3255 LANDMARK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29418-8461
Practice Address - Country:US
Practice Address - Phone:843-864-1661
Practice Address - Fax:843-628-1020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC159 BHS251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC159 BHSMedicaid