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General NPI Number Information
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NPI Number | 1689111379
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Entity Type | Organization
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Legal Business Name | MINDFULLY WHOLE PSYCHOTHERAPY LLC
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Dates
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Enumeration Date | 01/19/2017
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Last Update Date | 02/13/2017
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Provider Practice Location Address
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Address Line | 4057 W ILDEREEN ST
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City | SPRINGFIELD
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State | MO
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Zip | 65807-1063
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Country | US
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Telephone | 417-413-4991
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Fax | 417-719-7995
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Provider Business Mailing Address
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Address Line | 4057 W ILDEREEN ST
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City | SPRINGFIELD
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State | MO
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Zip | 65807-1063
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Country | US
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Telephone | 417-413-4991
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Fax | 417-719-7995
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Authorized Official
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Title or Position | OWNER
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Name | DR. BARBARA MANZER FARRELL
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Credential | PSYD
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Telephone | 417-413-4991
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 2016005653
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 2016005653
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License Number State | MO
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