Healthcare Provider Details

I. General information

NPI: 1063351815
Provider Name (Legal Business Name): MIND SHIFT WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 GRANITE ST STE 2
MILFORD MA
01757-1695
US

IV. Provider business mailing address

31 GRANITE ST STE 2
MILFORD MA
01757-1695
US

V. Phone/Fax

Practice location:
  • Phone: 508-933-1804
  • Fax:
Mailing address:
  • Phone: 508-306-1128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KENNETH MUTEGYEKI
Title or Position: DIRECTOR
Credential: PMHNP-BC
Phone: 508-306-1128