Provider Demographics
NPI:1487373056
Name:MINDFUL AUTHENTICITY, LLC
Entity type:Organization
Organization Name:MINDFUL AUTHENTICITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORNELAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-279-1187
Mailing Address - Street 1:1163 BELLEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-3840
Mailing Address - Country:US
Mailing Address - Phone:307-213-9484
Mailing Address - Fax:
Practice Address - Street 1:3360 ROAD 12
Practice Address - Street 2:
Practice Address - City:GREYBULL
Practice Address - State:WY
Practice Address - Zip Code:82426-9624
Practice Address - Country:US
Practice Address - Phone:702-791-1179
Practice Address - Fax:970-837-3401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-25
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty