Provider Demographics
NPI:1215682455
Name:MINDFUL WELLNESS LLC
Entity type:Organization
Organization Name:MINDFUL WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTLE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:443-359-1706
Mailing Address - Street 1:119 QUAIL TRL
Mailing Address - Street 2:
Mailing Address - City:BUXTON
Mailing Address - State:ME
Mailing Address - Zip Code:04093-3219
Mailing Address - Country:US
Mailing Address - Phone:443-359-1706
Mailing Address - Fax:
Practice Address - Street 1:100 BRICKHILL AVE STE 304
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:443-359-1706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)