MEDICARE: MIND BODY AND SOUL MENTAL HEALTH 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1548860893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND BODY AND SOUL MENTAL HEALTH COUNSELING PLLC

Provider Business Mailing Address
First Line	:	245 N MAIN ST UNIT 1241
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-7585
Country	:	US
Telephone Number	:	845-893-5384
Fax Number	:

Provider Business Practice Location Address
First Line	:	245 N MAIN ST UNIT 1241
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-7585
Country	:	US
Telephone Number	:	845-893-5384
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JENNA MCKEAN
Credential	:	LMHC
Telephone Number	:	845-893-5384

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	10/27/2020

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