Provider Demographics
NPI:1578286506
Name:MINDFULLY, LLC
Entity type:Organization
Organization Name:MINDFULLY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:K
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LPCC-S, LICDC-C
Authorized Official - Phone:888-830-0347
Mailing Address - Street 1:1251 NILLES RD STE 5
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-7205
Mailing Address - Country:US
Mailing Address - Phone:888-830-0347
Mailing Address - Fax:
Practice Address - Street 1:2025 GUADALUPE ST STE 260
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-5642
Practice Address - Country:US
Practice Address - Phone:888-830-0347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINDFULLY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-09-23
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty