Provider Demographics
NPI:1003689217
Name:MINDFUL SUPPORT PLLC
Entity type:Organization
Organization Name:MINDFUL SUPPORT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-536-4495
Mailing Address - Street 1:38W463 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-6178
Mailing Address - Country:US
Mailing Address - Phone:630-640-3539
Mailing Address - Fax:
Practice Address - Street 1:110 N BROCKWAY ST STE 300
Practice Address - Street 2:
Practice Address - City:PALATINE
Practice Address - State:IL
Practice Address - Zip Code:60067-5063
Practice Address - Country:US
Practice Address - Phone:630-640-3539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty