Basic Information
| Provider Information | |||||||||
| NPI: | 1780095968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MINDWIRE THERAPY, INC | ||||||||
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| OtherOrganizationName: | MINDWIRE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 CORBETT ST | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BELLEAIR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337567309 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 CORBETT ST | ||||||||
| Address2: | SUITE 460 | ||||||||
| City: | BELLEAIR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337567309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273866495 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2014 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | THEIS | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDRA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4072235423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH11558 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | MH11310 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.