Healthcare Provider Details

I. General information

NPI: 1083461321
Provider Name (Legal Business Name): MINDSCAPE PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/03/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8695 MEADOW LN
BERRIEN SPRINGS MI
49103-1426
US

IV. Provider business mailing address

115 N MAIN ST #320
BERRIEN SPRINGS MI
49103-1766
US

V. Phone/Fax

Practice location:
  • Phone: 269-240-8915
  • Fax:
Mailing address:
  • Phone: 269-240-8915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. ANGELA ST. HILLAIRE
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 269-240-8915