Provider Demographics
NPI:1235973371
Name:MIND GLOW THERAPY LLC
Entity type:Organization
Organization Name:MIND GLOW THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-300-0063
Mailing Address - Street 1:4440 58TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-1017
Mailing Address - Country:US
Mailing Address - Phone:727-300-0063
Mailing Address - Fax:727-594-4048
Practice Address - Street 1:4440 58TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33714-1017
Practice Address - Country:US
Practice Address - Phone:727-300-0063
Practice Address - Fax:727-594-4048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty