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General NPI Number Information
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NPI Number | 1902311269
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Entity Type | Organization
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Legal Business Name | MENDING MINDS THERAPY LLC
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Dates
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Enumeration Date | 12/08/2017
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Last Update Date | 12/08/2017
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Provider Practice Location Address
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Address Line | 725 W CENTRAL AVE STE 208
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City | MISSOULA
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State | MT
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Zip | 59801-6800
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Country | US
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Telephone | 406-926-1231
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Fax | 406-926-1231
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Provider Business Mailing Address
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Address Line | 725 W CENTRAL AVE STE 208
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City | MISSOULA
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State | MT
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Zip | 59801-6800
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Country | US
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Telephone | 406-926-1231
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Fax | 406-926-1231
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Authorized Official
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Title or Position | LCSW
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Name | JUSTINA K HAGEN
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Credential | LCSW
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Telephone | 406-926-1231
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | BBH-LCSW-LIC-18186
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License Number State | MT
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