=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205634375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENDING MINDS BEHAVIORAL HEALTH INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2025
-----------------------------------------------------
Last Update Date | 03/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17752 COLLINS CIR
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-856-7545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17752 COLLINS CIR
-----------------------------------------------------
City | HUNTINGTON BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92647-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-856-7545
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COMPLIANCE DIRECTOR
-----------------------------------------------------
Name | MR. DANIEL MATTHEW AVDEE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-412-4477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------