Healthcare Provider Details

I. General information

NPI: 1639933732
Provider Name (Legal Business Name): MIND LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24014 W RENWICK RD STE 105-5
PLAINFIELD IL
60544-8708
US

IV. Provider business mailing address

13855 S PETERSBURG DR
PLAINFIELD IL
60544-7078
US

V. Phone/Fax

Practice location:
  • Phone: 815-200-1099
  • Fax:
Mailing address:
  • Phone: 815-200-1099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ANGELA OLSON
Title or Position: OWNER AND CLINICAL THERAPIST
Credential: LCPC
Phone: 815-200-1099