Provider Demographics
NPI:1316621014
Name:MINDVALLEY BEHAVIORAL HEALTH CENTER LLC
Entity type:Organization
Organization Name:MINDVALLEY BEHAVIORAL HEALTH CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTI
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEMORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-989-7777
Mailing Address - Street 1:2737 E GREENWAY ROAD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4391
Mailing Address - Country:US
Mailing Address - Phone:623-404-4797
Mailing Address - Fax:480-546-4297
Practice Address - Street 1:2737 E GREENWAY ROAD
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4391
Practice Address - Country:US
Practice Address - Phone:623-404-4797
Practice Address - Fax:480-546-4297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health