Healthcare Provider Details

I. General information

NPI: 1376160820
Provider Name (Legal Business Name): MIND MATTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 10/22/2021
Certification Date: 10/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1875 N LAKEWOOD DR STE 101
COEUR D ALENE ID
83814-4928
US

IV. Provider business mailing address

1875 N LAKEWOOD DR STE 101
COEUR D ALENE ID
83814-4928
US

V. Phone/Fax

Practice location:
  • Phone: 208-719-9110
  • Fax:
Mailing address:
  • Phone: 208-719-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAMES SMIDT
Title or Position: OWNER
Credential:
Phone: 855-621-8250