=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922544063
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND SPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2017
-----------------------------------------------------
Last Update Date | 02/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 5TH AVE S
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34102-6575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-307-0886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3210 66TH ST SW
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34105-7322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-321-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST/DIRECTOR
-----------------------------------------------------
Name | DR. LAUREN K MASON
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 202-321-9117
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PY9595
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------