MEDICARE: MIND WELLNESS COUNSELING

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	:	1790325785
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND WELLNESS COUNSELING

Provider Business Mailing Address
First Line	:	123 S. MAIN ST.
Second Line	:	SUITE 100
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-0945
Country	:	US
Telephone Number	:	248-692-4013
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 S. MAIN ST.
Second Line	:	SUITE 100
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-0945
Country	:	US
Telephone Number	:	248-692-4013
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHAEL JAY SAMAR JR.
Credential	:	LMSW
Telephone Number	:	248-692-4013

Provider Enumeration Date	:	01/08/2020
Last Update Date	:	05/12/2021

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