MEDICARE: MIND AND BRAIN CARE LLC

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	103TC1900X	Counseling Psychologist	PY7375	FL
2	103TC2200X	Clinical Child & Adolescent Psychologist	PY7375	FL
3	103TF0200X	Forensic Psychologist	PY7375	FL
4	103TM1800X	Intellectual & Developmental Disabilities Psychologist	PY7375	FL
5	103TB0200X	Cognitive & Behavioral Psychologist	PY7375	FL
6	103TC0700X	Clinical Psychologist	PY7375	FL
7	103G00000X	Clinical Neuropsychologist	PY7375	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	75725	OTHER	FL	BCBS
2	6022640	OTHER	FL	CIGNA

General Provider Information

NPI Number	:	1942516844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND AND BRAIN CARE LLC

Provider Business Mailing Address
First Line	:	10175 6 MILE CYPRESS PKWY
Second Line	:	SUITE 3
City	:	FORT MYERS
State	:	FL
Zip	:	33966-9663
Country	:	US
Telephone Number	:	239-768-6500
Fax Number	:	239-768-6421

Provider Business Practice Location Address
First Line	:	10175 6 MILE CYPRESS PKWY STE 3
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-6993
Country	:	US
Telephone Number	:	239-768-6500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MABEL LOPEZ
Credential	:	PHD
Telephone Number	:	239-768-6500

Provider Enumeration Date	:	08/30/2010
Last Update Date	:	12/11/2023

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Directions to “MIND AND BRAIN CARE LLC ” Practice Location

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