Provider Demographics
NPI:1457937989
Name:MINDFULLY BALANCED THERAPY PLLC
Entity type:Organization
Organization Name:MINDFULLY BALANCED THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGAR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-447-2919
Mailing Address - Street 1:10020 MONROE RD STE 170-228
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5485
Mailing Address - Country:US
Mailing Address - Phone:847-447-2919
Mailing Address - Fax:
Practice Address - Street 1:10020 MONROE RD STE 170-228
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5485
Practice Address - Country:US
Practice Address - Phone:847-447-2919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-23
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health