MEDICARE: MIDE INTEGRATIVE THERAPIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1003503897
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDE INTEGRATIVE THERAPIES

Provider Business Mailing Address
First Line	:	3408 W 3RD AVE
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99224-1209
Country	:	US
Telephone Number	:	707-337-6721
Fax Number	:

Provider Business Practice Location Address
First Line	:	1516 W RIVERSIDE AVE STE 208
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99201-1241
Country	:	US
Telephone Number	:	707-337-6721
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HEATHER HART
Credential	:	LMHC
Telephone Number	:	707-337-6721

Provider Enumeration Date	:	04/20/2023
Last Update Date	:	04/20/2023

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