Provider Demographics
NPI:1952889305
Name:FIT MIND WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:FIT MIND WELLNESS CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:REGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:681-378-2134
Mailing Address - Street 1:1017 6TH AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2348
Mailing Address - Country:US
Mailing Address - Phone:681-378-2134
Mailing Address - Fax:
Practice Address - Street 1:1017 6TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-2348
Practice Address - Country:US
Practice Address - Phone:681-378-2134
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-29
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVDP00945023104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1568808137OtherNPI