Provider Demographics
NPI:1952022527
Name:UNTANGLED MINDS PLLC
Entity Type:Organization
Organization Name:UNTANGLED MINDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:618-468-8069
Mailing Address - Street 1:807 W HIGHWAY 50 STE 3
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1856
Mailing Address - Country:US
Mailing Address - Phone:618-468-8069
Mailing Address - Fax:
Practice Address - Street 1:807 W HIGHWAY 50 STE 3
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1856
Practice Address - Country:US
Practice Address - Phone:618-468-8069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-12
Last Update Date:2023-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)