Healthcare Provider Details

I. General information

NPI: 1033876495
Provider Name (Legal Business Name): MINDFULLY MAGNIFIED MENTAL HEALTH AND CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2021
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12940 HARRIET AVE S STE 110
BURNSVILLE MN
55337-2680
US

IV. Provider business mailing address

12940 HARRIET AVE S STE 110
BURNSVILLE MN
55337-2680
US

V. Phone/Fax

Practice location:
  • Phone: 651-300-9493
  • Fax: 651-927-0210
Mailing address:
  • Phone: 651-300-9493
  • Fax: 651-927-0210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: CELIA SMITH
Title or Position: OWNER, CLINICAL DIRECTOR
Credential: LICSW
Phone: 651-300-9493