Healthcare Provider Details

I. General information

NPI: 1376271981
Provider Name (Legal Business Name): MINDFULLY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 DEERWOOD PARK BLVD STE 250
JACKSONVILLE FL
32256-0566
US

IV. Provider business mailing address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

V. Phone/Fax

Practice location:
  • Phone: 888-830-0347
  • Fax: 513-939-0310
Mailing address:
  • Phone: 888-830-0347
  • Fax: 513-939-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: CHARLES K ROBERTS
Title or Position: AUTHORIZED OFFICIAL
Credential: EDD, LPCC-S, LICDC-C
Phone: 888-830-0347