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General NPI Number Information
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NPI Number | 1154983765
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Entity Type | Organization
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Legal Business Name | MINDFUL BEHAVIOR SUPPORT INC
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Dates
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Enumeration Date | 07/03/2019
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Last Update Date | 07/03/2019
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Provider Practice Location Address
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Address Line | 492 E 13TH AVE
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City | EUGENE
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State | OR
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Zip | 97401-4268
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Country | US
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Telephone | 541-520-6440
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 210
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City | DEXTER
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State | OR
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Zip | 97431-0210
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Country | US
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Telephone | 541-520-6440
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JENNIFER WELLS
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Credential | PH.D.
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Telephone | 541-520-6440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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