Healthcare Provider Details

I. General information

NPI: 1053878413
Provider Name (Legal Business Name): MANDALA THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 SAINT CHRISTOPHER DR
ASHLAND KY
41101-7064
US

IV. Provider business mailing address

1201 SAINT CHRISTOPHER DR
ASHLAND KY
41101-7064
US

V. Phone/Fax

Practice location:
  • Phone: 606-388-2898
  • Fax:
Mailing address:
  • Phone: 606-388-2898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER SMITH
Title or Position: OWNER
Credential: LCSW
Phone: 606-388-2898