Provider Demographics
NPI:1013676345
Name:MINDLIFT LLC
Entity Type:Organization
Organization Name:MINDLIFT LLC
Other - Org Name:MINDLIFT LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GM
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:WITTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-655-6026
Mailing Address - Street 1:519 LICKING PIKE
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2941
Mailing Address - Country:US
Mailing Address - Phone:859-572-0400
Mailing Address - Fax:859-442-3363
Practice Address - Street 1:519 LICKING PIKE
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41071-2941
Practice Address - Country:US
Practice Address - Phone:859-572-0400
Practice Address - Fax:859-442-3363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100926170Medicaid