Healthcare Provider Details

I. General information

NPI: 1356002612
Provider Name (Legal Business Name): MINDFUL MINOTAUR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MCGEE DR STE 104
NORMAN OK
73072-6705
US

IV. Provider business mailing address

200 MIDWAY DR
NORMAN OK
73072-4321
US

V. Phone/Fax

Practice location:
  • Phone: 405-276-4747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA BOURNIVAL
Title or Position: OWNER
Credential: MSBS, LMFT
Phone: 405-276-4747