Provider Demographics
NPI:1902398233
Name:MINDMEND
Entity Type:Organization
Organization Name:MINDMEND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:989-506-9025
Mailing Address - Street 1:935 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48906-5137
Mailing Address - Country:US
Mailing Address - Phone:989-506-9025
Mailing Address - Fax:989-779-2922
Practice Address - Street 1:935 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5137
Practice Address - Country:US
Practice Address - Phone:989-506-9025
Practice Address - Fax:989-779-2922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401008490101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1588935811Medicaid