Provider Demographics
NPI:1447894209
Name:MINDFUL THERAPY STUDIO LLC
Entity type:Organization
Organization Name:MINDFUL THERAPY STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-967-8941
Mailing Address - Street 1:16 RAE PALMER RD
Mailing Address - Street 2:
Mailing Address - City:MOODUS
Mailing Address - State:CT
Mailing Address - Zip Code:06469-1195
Mailing Address - Country:US
Mailing Address - Phone:860-967-8941
Mailing Address - Fax:
Practice Address - Street 1:16 RAE PALMER RD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-1195
Practice Address - Country:US
Practice Address - Phone:860-967-8941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT047660231Medicaid