Mind Glow Therapy LLC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

Legal business name

MIND GLOW THERAPY LLC

Practice address

4440 58TH Ave N
St Petersburg, FL 33714-1017

Phone

(727) 300-0063

Fax

(727) 594-4048

NPI assigned

Jun 24, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ronald D Dayton

Title

Credentialing Manager

Phone

(727) 300-0063

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1719187200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1719187200000",
    "number": "1235973371",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4440 58TH AVE N",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337141017",
            "telephone_number": "727-300-0063",
            "fax_number": "727-594-4048"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4440 58TH AVE N",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337141017",
            "telephone_number": "727-300-0063",
            "fax_number": "727-594-4048"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIND GLOW THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-06-24",
        "last_updated": "2024-06-24",
        "certification_date": "2024-06-24",
        "status": "A",
        "authorized_official_last_name": "DAYTON",
        "authorized_official_first_name": "RONALD",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CREDENTIALING MANAGER",
        "authorized_official_telephone_number": "727-300-0063"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Social Worker in St Petersburg, FL
• Providers in St Petersburg, FL by specialty
• Clinical Social Worker in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.