Healthcare Provider Details

I. General information

NPI: 1114608080
Provider Name (Legal Business Name): INTENTIONAL MINDED COUNSELING & CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HIGHWAY 51 SUITE B
RIDGELAND MS
39157
US

IV. Provider business mailing address

201 HIGHWAY 51, SUITE B
RIDGELAND MS
39157
US

V. Phone/Fax

Practice location:
  • Phone: 601-519-1011
  • Fax: 601-822-6009
Mailing address:
  • Phone: 601-519-1011
  • Fax: 601-822-6009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: ROBERT LOCK
Title or Position: CO-OWNER
Credential: LPC
Phone: 601-519-1011