MEDICARE: MIGHTY WARRIOR WELLNESS, PC

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	101YP2500X	Professional Counselor
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1083345458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIGHTY WARRIOR WELLNESS, PC

Provider Business Mailing Address
First Line	:	125 S BROADWAY ST
Second Line	:
City	:	CASSOPOLIS
State	:	MI
Zip	:	49031-1242
Country	:	US
Telephone Number	:	269-414-8534
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 S BROADWAY ST
Second Line	:
City	:	CASSOPOLIS
State	:	MI
Zip	:	49031-1242
Country	:	US
Telephone Number	:	269-414-8534
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CARLA LOWE
Credential	:	LPC, CAADC
Telephone Number	:	269-414-8534

Provider Enumeration Date	:	06/17/2022
Last Update Date	:	06/17/2022

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