Healthcare Provider Details

I. General information

NPI: 1477204881
Provider Name (Legal Business Name): OPEN MIND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S FRANCES ST
SOUTH BEND IN
46617-3004
US

IV. Provider business mailing address

222 S FRANCES ST
SOUTH BEND IN
46617-3004
US

V. Phone/Fax

Practice location:
  • Phone: 574-210-0771
  • Fax: 574-314-6486
Mailing address:
  • Phone: 574-210-0771
  • Fax: 574-314-6486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL WHITLOW
Title or Position: OWNER/EMPLOYEE
Credential: LCSW
Phone: 574-210-0771