Provider Demographics
NPI:1154580538
Name:MIND SPA INC
Entity type:Organization
Organization Name:MIND SPA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:GROVER
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:972-780-5160
Mailing Address - Street 1:1801 N HAMPTON RD STE 410
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-2338
Mailing Address - Country:US
Mailing Address - Phone:972-780-5160
Mailing Address - Fax:
Practice Address - Street 1:1801 N HAMPTON RD STE 410
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2338
Practice Address - Country:US
Practice Address - Phone:972-780-5160
Practice Address - Fax:972-780-5735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19695103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9017LCOtherBCBS