Healthcare Provider Details

I. General information

NPI: 1467980300
Provider Name (Legal Business Name): MINDFUL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 N MAPLE ST
ITHACA MI
48847-1024
US

IV. Provider business mailing address

122 N MAPLE ST
ITHACA MI
48847-1024
US

V. Phone/Fax

Practice location:
  • Phone: 989-388-4185
  • Fax: 989-388-4187
Mailing address:
  • Phone: 989-388-4185
  • Fax: 989-388-4187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberSA0290035
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSA0290035
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSA0190019
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSA0290035
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSA0190019
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberSA0190019
License Number StateMI

VIII. Authorized Official

Name: AUDREY ANN WENDT
Title or Position: EXECUTIVE DIRECTOR/OWNER
Credential: MSW, LMSW, CAADC
Phone: 989-388-4185