MEDICARE: WINDSONG WELLNESS, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261QM0850X	Adult Mental Health Clinic/Center
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1184245144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WINDSONG WELLNESS, LLC

Provider Business Mailing Address
First Line	:	1238 SW AVENS ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-2506
Country	:	US
Telephone Number	:	772-465-4044
Fax Number	:	772-468-6894

Provider Business Practice Location Address
First Line	:	1562 SE VILLAGE GREEN DR STE 5AND7
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34952-5100
Country	:	US
Telephone Number	:	772-465-4044
Fax Number	:	772-468-6894

Authorized Official
Title or Position	:	CEO
Name	:	MR. BRETT LIEBERMAN
Credential	:	LMFT
Telephone Number	:	772-465-4044

Provider Enumeration Date	:	04/30/2020
Last Update Date	:	05/11/2020

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Directions to “WINDSONG WELLNESS, LLC ” Practice Location

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