Provider Demographics
NPI:1902311269
Name:MENDING MINDS THERAPY LLC
Entity Type:Organization
Organization Name:MENDING MINDS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-926-1231
Mailing Address - Street 1:725 W CENTRAL AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-6800
Mailing Address - Country:US
Mailing Address - Phone:406-926-1231
Mailing Address - Fax:406-926-1231
Practice Address - Street 1:725 W CENTRAL AVE STE 208
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-6800
Practice Address - Country:US
Practice Address - Phone:406-926-1231
Practice Address - Fax:406-926-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-LCSW-LIC-181861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty