Healthcare Provider Details

I. General information

NPI: 1255192050
Provider Name (Legal Business Name): MINDSIITE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 E OAK ST
KISSIMMEE FL
34744-4580
US

IV. Provider business mailing address

715 E OAK ST
KISSIMMEE FL
34744-4580
US

V. Phone/Fax

Practice location:
  • Phone: 352-284-4043
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. VIVIAN CHARNECO
Title or Position: PRESIDENT/BOARD MEMBER
Credential: MD
Phone: 352-284-4043