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General NPI Number Information
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NPI Number | 1912714486
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Entity Type | Organization
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Legal Business Name | MINDIVE
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Dates
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Enumeration Date | 12/17/2024
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Last Update Date | 12/17/2024
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Provider Practice Location Address
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Address Line | 119 S SHERRIN AVE STE 240
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City | LOUISVILLE
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State | KY
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Zip | 40207-3237
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Country | US
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Telephone | 502-509-6002
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Fax | 502-415-7263
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Provider Business Mailing Address
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Address Line | 119 S SHERRIN AVE STE 240
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City | LOUISVILLE
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State | KY
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Zip | 40207-3237
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Country | US
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Telephone | 502-509-6002
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Fax | 502-415-7263
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Authorized Official
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Title or Position | OWNER
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Name | JESSICA FLORES
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Credential | LPAT
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Telephone | 502-386-1938
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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