MEDICARE: MINDFUL BEHAVIOR

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	:	1558035519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL BEHAVIOR

Provider Business Mailing Address
First Line	:	PO BOX 388556
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-8556
Country	:	US
Telephone Number	:	708-304-3010
Fax Number	:	708-575-5333

Provider Business Practice Location Address
First Line	:	6815 W 63RD ST STE 7
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-4066
Country	:	US
Telephone Number	:	708-304-3010
Fax Number	:	708-575-5333

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ELISA J LEE
Credential	:	LCPC
Telephone Number	:	708-304-3010

Provider Enumeration Date	:	08/04/2021
Last Update Date	:	03/27/2023

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Directions to “MINDFUL BEHAVIOR ” Practice Location

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