Healthcare Provider Details

I. General information

NPI: 1912843020
Provider Name (Legal Business Name): MENDING MINDS COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 SE H ST
GRANTS PASS OR
97526-3038
US

IV. Provider business mailing address

4750 CLOVERLAWN DR
GRANTS PASS OR
97527-8951
US

V. Phone/Fax

Practice location:
  • Phone: 541-450-9351
  • 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

VIII. Authorized Official

Name: LATARA WILSON
Title or Position: LPC/ MEMBER
Credential: MS
Phone: 541-450-9351