MEDICARE: MINDFUL CHAOS COUNSELING, PLLC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1518798008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL CHAOS COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	30 2ND ST E STE B28
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4563
Country	:	US
Telephone Number	:	406-270-6265
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 2ND ST E STE B28
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-4563
Country	:	US
Telephone Number	:	406-270-6265
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CHEYENNE WHITE
Credential	:	SWLC, LAC
Telephone Number	:	406-270-6265

Provider Enumeration Date	:	08/08/2024
Last Update Date	:	08/08/2024

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