MEDICARE: MIND AND WELLNESS HEALTHCARE SERVICES

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	:	1427819762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND AND WELLNESS HEALTHCARE SERVICES

Provider Business Mailing Address
First Line	:	11223 46TH PL N
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-9137
Country	:	US
Telephone Number	:	156-185-6428
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 LAKE WORTH RD STE 209-8
Second Line	:
City	:	GREENACRES
State	:	FL
Zip	:	33463-3275
Country	:	US
Telephone Number	:	561-856-4285
Fax Number	:

Authorized Official
Title or Position	:	NP
Name	:	MANOUCHKA MILDOR
Credential	:	PMHNP
Telephone Number	:	561-258-4867

Provider Enumeration Date	:	01/23/2024
Last Update Date	:	01/23/2024

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