Provider Demographics
NPI:1992015689
Name:MENDING HEARTS LLC
Entity Type:Organization
Organization Name:MENDING HEARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOMAHCHEET
Authorized Official - Suffix:
Authorized Official - Credentials:LADC, ICAADC
Authorized Official - Phone:405-213-3700
Mailing Address - Street 1:PO BOX 890900
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73189-0900
Mailing Address - Country:US
Mailing Address - Phone:405-821-7767
Mailing Address - Fax:
Practice Address - Street 1:3212 SW 104TH TER
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7800
Practice Address - Country:US
Practice Address - Phone:405-821-7767
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15525610002251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health