Healthcare Provider Details

I. General information

NPI: 1104755008
Provider Name (Legal Business Name): MINDFULLY TEXAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 SHOAL CREEK BLVD STE 4-202A
AUSTIN TX
78757-7591
US

IV. Provider business mailing address

10290 ALLIANCE RD
BLUE ASH OH
45242-4710
US

V. Phone/Fax

Practice location:
  • Phone: 737-257-0829
  • Fax: 800-583-9889
Mailing address:
  • Phone: 737-257-0829
  • Fax: 800-853-9889

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 Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY TAIT-MOSS
Title or Position: SVP
Credential:
Phone: 954-380-1507