Provider Demographics
NPI:1144040478
Name:MIND BLOSSOM RECOVERY
Entity type:Organization
Organization Name:MIND BLOSSOM RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KORTNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:407-583-4499
Mailing Address - Street 1:3003 CLAMONT LN
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2045
Mailing Address - Country:US
Mailing Address - Phone:407-492-9245
Mailing Address - Fax:
Practice Address - Street 1:2110 N DONNELLY ST STE 103
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6969
Practice Address - Country:US
Practice Address - Phone:407-492-4945
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health