=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558035428
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OHIO MINDFUL PSYCHOTHERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2021
-----------------------------------------------------
Last Update Date | 08/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11826 GALLIA PIKE RD STE C
-----------------------------------------------------
City | WHEELERSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45694-9119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-285-7460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 STENNETT RD
-----------------------------------------------------
City | WHEELERSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45694-8929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-357-7803
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/COUNSELOR
-----------------------------------------------------
Name | JESSICA RENEE TRIPLETT
-----------------------------------------------------
Credential | M.ED., LPCC-S
-----------------------------------------------------
Telephone | 740-357-7803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------