Healthcare Provider Details

I. General information

NPI: 1174265383
Provider Name (Legal Business Name): MINDFUL CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/08/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 1/2 WESTWOOD BLVD, SUITE 4
LOS ANGELES CA
90025
US

IV. Provider business mailing address

1923 1/2 WESTWOOD BLVD, SUITE 4
LOS ANGELES CA
90025
US

V. Phone/Fax

Practice location:
  • Phone: 747-228-2621
  • Fax:
Mailing address:
  • Phone: 747-228-2621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. SAMANTHA WRIGHT WAKACH
Title or Position: CO-FOUNDER, MINDFUL CLINICAL SERVIC
Credential: LCSW
Phone: 747-228-2621