MEDICARE: MIND & BODY INTEGRATIVE COUNSELING CENTER

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	106H00000X	Marriage & Family Therapist
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1518709161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND & BODY INTEGRATIVE COUNSELING CENTER

Provider Business Mailing Address
First Line	:	9000 SHERIDAN ST STE 154
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-8801
Country	:	US
Telephone Number	:	954-281-2626
Fax Number	:	954-281-5946

Provider Business Practice Location Address
First Line	:	9000 SHERIDAN ST STE 154
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-8801
Country	:	US
Telephone Number	:	954-281-2626
Fax Number	:	954-281-5946

Authorized Official
Title or Position	:	OWNER/LICENSED COUNSELOR
Name	:	TAYLOR NICOLE ROSAND
Credential	:	MS
Telephone Number	:	954-281-2626

Provider Enumeration Date	:	06/12/2024
Last Update Date	:	06/12/2024

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