Provider Demographics
NPI:1922283464
Name:MENDED HEARTS
Entity Type:Organization
Organization Name:MENDED HEARTS
Other - Org Name:MENDED HEARTS STABLE, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:SELLNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:309-383-4323
Mailing Address - Street 1:1431 LOURDES RD
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:IL
Mailing Address - Zip Code:61548-7609
Mailing Address - Country:US
Mailing Address - Phone:309-383-4323
Mailing Address - Fax:309-383-3399
Practice Address - Street 1:1431 LOURDES RD
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:IL
Practice Address - Zip Code:61548-7609
Practice Address - Country:US
Practice Address - Phone:309-383-4323
Practice Address - Fax:309-383-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005723251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health