Healthcare Provider Details

I. General information

NPI: 1902195464
Provider Name (Legal Business Name): MENDING MINDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 04/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SPRING VALLEY RD
EAST LONGMEADOW MA
01028-2513
US

IV. Provider business mailing address

24 SPRING VALLEY RD
EAST LONGMEADOW MA
01028-2513
US

V. Phone/Fax

Practice location:
  • Phone: 413-530-3273
  • Fax:
Mailing address:
  • Phone: 413-530-3273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number195411
License Number StateMA

VIII. Authorized Official

Name: MS. LAURIE KIMBALL
Title or Position: PRESIDENT
Credential: APRN NP
Phone: 413-530-3273