MEDICARE: MINDLAB LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1295515765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDLAB LLC

Provider Business Mailing Address
First Line	:	2423 HIGHWAY 17 S
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-4343
Country	:	US
Telephone Number	:	843-321-5099
Fax Number	:

Provider Business Practice Location Address
First Line	:	2423 HIGHWAY 17 S
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-4343
Country	:	US
Telephone Number	:	843-321-5099
Fax Number	:

Authorized Official
Title or Position	:	PMHNP/PARTNER
Name	:	STACEY SHAW
Credential	:	APRN
Telephone Number	:	843-321-5099

Provider Enumeration Date	:	10/03/2023
Last Update Date	:	10/03/2023

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