Provider Demographics
NPI:1932862513
Name:K VILLE LLC
Entity Type:Organization
Organization Name:K VILLE LLC
Other - Org Name:MINDFUL HEALING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICIAN/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATY
Authorized Official - Middle Name:
Authorized Official - Last Name:REDEL
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:386-402-8346
Mailing Address - Street 1:2102 S RIDGEWOOD AVE STE 17
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-4230
Mailing Address - Country:US
Mailing Address - Phone:386-402-8346
Mailing Address - Fax:
Practice Address - Street 1:2102 S RIDGEWOOD AVE STE 17
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-4230
Practice Address - Country:US
Practice Address - Phone:386-402-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021586900Medicaid
13995716OtherCAQH