Provider Demographics
NPI:1902195464
Name:MENDING MINDS
Entity Type:Organization
Organization Name:MENDING MINDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN NP
Authorized Official - Phone:413-530-3273
Mailing Address - Street 1:24 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-2513
Mailing Address - Country:US
Mailing Address - Phone:413-530-3273
Mailing Address - Fax:
Practice Address - Street 1:24 SPRING VALLEY RD
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-2513
Practice Address - Country:US
Practice Address - Phone:413-530-3273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA195411261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000767402OtherMEDICARE PTAN
020874OtherMBHP