Provider Demographics
NPI:1902234453
Name:MINDFUL LIFE IN ACTION
Entity Type:Organization
Organization Name:MINDFUL LIFE IN ACTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S, LICDC
Authorized Official - Phone:567-241-1543
Mailing Address - Street 1:PO BOX 290
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-0290
Mailing Address - Country:US
Mailing Address - Phone:567-241-1543
Mailing Address - Fax:
Practice Address - Street 1:380 CLINE AVE STE 3
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-1056
Practice Address - Country:US
Practice Address - Phone:567-241-1543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-21
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHICDC131026101YA0400X
OHI1200473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0906532Medicaid