=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962204305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENDING HEARTS THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2025
-----------------------------------------------------
Last Update Date | 03/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6506 S LEWIS AVE STE 105
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-1020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-890-1103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17745 E 100TH ST N
-----------------------------------------------------
City | OWASSO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74055-7728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-890-1103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOTHERAPIST
-----------------------------------------------------
Name | LAURA JAMES
-----------------------------------------------------
Credential | LPC-S
-----------------------------------------------------
Telephone | 981-890-1103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------