Provider Demographics
NPI:1992379234
Name:MINDWORKS MENTAL HEALTH
Entity Type:Organization
Organization Name:MINDWORKS MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREGUD-AKSIMENTYEVA
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:217-721-3263
Mailing Address - Street 1:3303 S PINE CIR
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-7130
Mailing Address - Country:US
Mailing Address - Phone:217-721-3263
Mailing Address - Fax:
Practice Address - Street 1:328 N. NEIL. ST, SUIT B
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3949
Practice Address - Country:US
Practice Address - Phone:217-722-6336
Practice Address - Fax:217-354-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL33602Medicaid