NPIMap

Organization Active NPI

Mindfully, LLC

  • Counselor
  • Jacksonville, FL
National Provider Identifier
1376271981
Registry record updated Aug 6, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
CounselorTaxonomy code 101Y00000X
Legal business name
MINDFULLY, LLC
Practice address
10151 Deerwood Park Blvd Ste 250
Jacksonville, FL 32256-0566
Phone
(888) 830-0347
Fax
(513) 939-0310
NPI assigned
Aug 11, 2022
Last updated
Aug 6, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
MINDFULLY, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Aug 6, 2024

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

Authorized official

Name
Charles K Roberts, EDD, LPCC-S, LICDC-CNPI 1225199912
Title
Authorized Official
Phone
(888) 830-0347

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 8

Specialty (taxonomy)CodeLicenseStatePrimary
CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101Y00000X Primary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X
Mental Health CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YM0800X
PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103T00000X
Social WorkerGroup: 193200000X MULTI-SPECIALTY GROUP 104100000X
Marriage & Family TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 106H00000X
Case Manager/Care CoordinatorGroup: 193200000X MULTI-SPECIALTY GROUP 171M00000X
Peer SpecialistGroup: 193200000X MULTI-SPECIALTY GROUP 175T00000X

Addresses

Primary practice location

10151 Deerwood Park Blvd Ste 250
Jacksonville, FL 32256-0566

Mailing address

1251 Nilles Rd Ste 5
Fairfield, OH 45014-7205
Phone (888) 830-0347

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240621000910 FL Part B Supplier - Clinic/Group Practice 3476606252 Receives reassigned benefits from 1 practitioner
Practice locations: Jacksonville, FL

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Compass Point11 organizations share this tax ID, including this one
Part of
Compass Point

Other organizations with this tax ID 10

Organizations that report the same tax identification number in the National Provider Directory.

Locations

199 S Chillicothe Rd
Ste 207
Aurora, OH 44202

463 Ohio Pike
Ste 102B
Cincinnati, OH 45255
Phone (888) 262-3616

5520 Harrison Ave
Ste C
Cincinnati, OH 45248
Phone (513) 598-8324

8040 Hosbrook Rd
Ste 320
Cincinnati, OH 45236
Phone (513) 861-9797

8170 Corporate Park Dr
Ste 312
Cincinnati, OH 45242

3615 Socialville Foster Rd
Ste D
Mason, OH 45040
Phone (513) 204-1910

Practitioners & affiliated clinicians

Practitioners 177

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 177

NPI Registry JSON

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

{
    "created_epoch": "1660176000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722902400000",
    "number": "1376271981",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1251 NILLES RD STE 5",
            "city": "FAIRFIELD",
            "state": "OH",
            "postal_code": "450147205",
            "telephone_number": "888-830-0347",
            "fax_number": "513-939-0310"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10151 DEERWOOD PARK BLVD STE 250",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322560566",
            "telephone_number": "888-830-0347",
            "fax_number": "513-939-0310"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MINDFULLY, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MINDFULLY, LLC",
        "enumeration_date": "2022-08-11",
        "last_updated": "2024-08-06",
        "certification_date": "2024-08-06",
        "status": "A",
        "authorized_official_last_name": "ROBERTS",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "AUTHORIZED OFFICIAL",
        "authorized_official_telephone_number": "888-830-0347",
        "authorized_official_credential": "EDD, LPCC-S, LICDC-C"
    },
    "taxonomies": [
        {
            "code": "101Y00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "106H00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Marriage & Family Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Case Manager/Care Coordinator",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "175T00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Peer Specialist",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Jacksonville, FL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 6, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.