MEDICARE: MENDING MINDS, HEALING HEARTS, 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	104100000X	Social Worker

General Provider Information

NPI Number	:	1457825606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENDING MINDS, HEALING HEARTS, LLC

Provider Business Mailing Address
First Line	:	536 MAPLE AVE
Second Line	:
City	:	LINWOOD
State	:	NJ
Zip	:	08221-1213
Country	:	US
Telephone Number	:	609-703-7849
Fax Number	:	609-904-5543

Provider Business Practice Location Address
First Line	:	536 MAPLE AVE
Second Line	:
City	:	LINWOOD
State	:	NJ
Zip	:	08221-1213
Country	:	US
Telephone Number	:	609-703-7849
Fax Number	:	609-904-5543

Authorized Official
Title or Position	:	OWNER, DIRECTOR
Name	:	KATHERINE C MATTLEMAN
Credential	:	LCSW
Telephone Number	:	609-703-7849

Provider Enumeration Date	:	01/21/2019
Last Update Date	:	01/21/2019

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