Provider Demographics
NPI:1912606997
Name:ENLIGHTENED MIND LLC
Entity Type:Organization
Organization Name:ENLIGHTENED MIND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:810-689-4547
Mailing Address - Street 1:2837 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2162
Mailing Address - Country:US
Mailing Address - Phone:810-858-1759
Mailing Address - Fax:
Practice Address - Street 1:2837 WALNUT ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2162
Practice Address - Country:US
Practice Address - Phone:810-689-4547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty