Provider Demographics
NPI:1780095968
Name:MINDWIRE THERAPY, INC
Entity type:Organization
Organization Name:MINDWIRE THERAPY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:THEIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-223-5423
Mailing Address - Street 1:401 CORBETT ST
Mailing Address - Street 2:SUITE 460
Mailing Address - City:BELLEAIR
Mailing Address - State:FL
Mailing Address - Zip Code:33756-7309
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 CORBETT ST
Practice Address - Street 2:SUITE 460
Practice Address - City:BELLEAIR
Practice Address - State:FL
Practice Address - Zip Code:33756-7309
Practice Address - Country:US
Practice Address - Phone:727-386-6495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-09
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11558101YM0800X
FLMH11310101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty