Provider Demographics
NPI:1760216915
Name:MINDESCAPE LLC
Entity type:Organization
Organization Name:MINDESCAPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHITOROGA
Authorized Official - Suffix:
Authorized Official - Credentials:RBT
Authorized Official - Phone:800-961-3367
Mailing Address - Street 1:27911 CROWN LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-4210
Mailing Address - Country:US
Mailing Address - Phone:800-961-3367
Mailing Address - Fax:800-961-3367
Practice Address - Street 1:27911 CROWN LAKE BLVD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4210
Practice Address - Country:US
Practice Address - Phone:800-961-3367
Practice Address - Fax:800-961-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty