Healthcare Provider Details

I. General information

NPI: 1366968554
Provider Name (Legal Business Name): MINDFUL HEALING THERAPY AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E DR MARTIN LUTHER KING JR BLVD STE 101
TAMPA FL
33603-3866
US

IV. Provider business mailing address

400 E DR MARTIN LUTHER KING JR BLVD STE 101
TAMPA FL
33603-3866
US

V. Phone/Fax

Practice location:
  • Phone: 813-236-4673
  • Fax: 813-236-4689
Mailing address:
  • Phone: 813-236-4673
  • Fax: 813-236-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW14306
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License NumberSW14306
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberSW14306
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberSW14306
License Number StateFL

VIII. Authorized Official

Name: MS. JESSICA R GREAVES
Title or Position: OWNER, PSYCHOTHERAPIST
Credential: MSW, LCSW
Phone: 813-505-6867