MEDICARE: THE IMIND FOUNDATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1041C0700X	Clinical Social Worker
2	2084P0800X	Psychiatry Physician
3	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1255172631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE IMIND FOUNDATION

Provider Business Mailing Address
First Line	:	160 NW CENTRAL PARK PLZ STE 104
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-1825
Country	:	US
Telephone Number	:	772-617-6373
Fax Number	:	844-440-1724

Provider Business Practice Location Address
First Line	:	145 NW CENTRAL PARK PLZ STE 112
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-2482
Country	:	US
Telephone Number	:	772-617-6373
Fax Number	:	844-440-1724

Authorized Official
Title or Position	:	CEO
Name	:	JUSTIN KALEL BAKSH
Credential	:	LMHC, MCAP
Telephone Number	:	772-617-6373

Provider Enumeration Date	:	06/01/2024
Last Update Date	:	06/01/2024

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Directions to “THE IMIND FOUNDATION ” Practice Location

Language	Start Address	Practice Location

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