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General NPI Number Information
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NPI Number | 1851972814
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Entity Type | Organization
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Legal Business Name | MINDFUL PERFORMANCE THERAPY, PLLC
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Dates
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Enumeration Date | 04/20/2021
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Last Update Date | 01/07/2022
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Provider Practice Location Address
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Address Line | 1414 TRADE CENTER DR STE 26-E
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City | TRAVERSE CITY
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State | MI
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Zip | 49696-8944
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Country | US
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Telephone | 989-370-0703
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Fax |
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Provider Business Mailing Address
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Address Line | 1414 TRADE CENTER DR STE 26-E
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City | TRAVERSE CITY
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State | MI
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Zip | 49696-8944
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Country | US
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Telephone | 989-370-0703
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DIANA VOLANT
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Credential | MA, LLP
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Telephone | 989-370-0703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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