Provider Demographics
NPI:1336923606
Name:INTENTIONAL MENTAL HEALTH & WELLNESS PLLC
Entity Type:Organization
Organization Name:INTENTIONAL MENTAL HEALTH & WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:936-657-8023
Mailing Address - Street 1:415 COUNTY ROAD 3794
Mailing Address - Street 2:
Mailing Address - City:JOAQUIN
Mailing Address - State:TX
Mailing Address - Zip Code:75954-2401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9626 STATE HIGHWAY 7 E
Practice Address - Street 2:
Practice Address - City:JOAQUIN
Practice Address - State:TX
Practice Address - Zip Code:75954-3986
Practice Address - Country:US
Practice Address - Phone:936-657-8023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-18
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty