Healthcare Provider Details

I. General information

NPI: 1285128785
Provider Name (Legal Business Name): MINDFULNESS BASED INTERVENTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 10/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 MAIN ST
DELTA CO
81416-1869
US

IV. Provider business mailing address

PO BOX 12
OURAY CO
81427-0012
US

V. Phone/Fax

Practice location:
  • Phone: 970-318-0529
  • Fax: 855-403-3931
Mailing address:
  • Phone: 970-318-0529
  • Fax: 855-403-3931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICHOLE L MOORMAN
Title or Position: OWNER
Credential: LCSW
Phone: 970-318-0529