Provider Demographics
NPI:1992133946
Name:MINDFUL BEHAVIORAL HEALTH PLLC
Entity type:Organization
Organization Name:MINDFUL BEHAVIORAL HEALTH PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CICHOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-499-6933
Mailing Address - Street 1:2201 NW CORPORATE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-7337
Mailing Address - Country:US
Mailing Address - Phone:561-499-6933
Mailing Address - Fax:561-235-5172
Practice Address - Street 1:2201 NW CORPORATE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-7337
Practice Address - Country:US
Practice Address - Phone:561-499-6933
Practice Address - Fax:561-235-5172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HT829AMedicare UPIN