Provider Demographics
NPI:1336735232
Name:MIND FULL THERAPY, LLC
Entity Type:Organization
Organization Name:MIND FULL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEASURE
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:801-828-6139
Mailing Address - Street 1:2827 S WAINWRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-1819
Mailing Address - Country:US
Mailing Address - Phone:801-828-6139
Mailing Address - Fax:
Practice Address - Street 1:2605 E 3300 S
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84109-2728
Practice Address - Country:US
Practice Address - Phone:801-828-6139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)