MEDICARE: MINDFUL THERAPY GROUP OF COLORADO, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	103TC0700X	Clinical Psychologist
3	106H00000X	Marriage & Family Therapist
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner
5	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1649092990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL THERAPY GROUP OF COLORADO, PC

Provider Business Mailing Address
First Line	:	6505 216TH ST SW STE 100
Second Line	:
City	:	MOUNTLAKE TERRACE
State	:	WA
Zip	:	98043-2089
Country	:	US
Telephone Number	:	425-678-6463
Fax Number	:	425-678-6455

Provider Business Practice Location Address
First Line	:	3711 JFK PKWY STE 310
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2658
Country	:	US
Telephone Number	:	970-422-7260
Fax Number	:	425-678-6455

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT MANAGER
Name	:	NICOLE PAULY
Credential	:
Telephone Number	:	425-640-7009

Provider Enumeration Date	:	10/28/2024
Last Update Date	:	10/28/2024

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