Healthcare Provider Details

I. General information

NPI: 1336615202
Provider Name (Legal Business Name): MINDFUL WAY COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2018
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MOORE LAKE DR E STE 152
FRIDLEY MN
55432-5135
US

IV. Provider business mailing address

1250 MOORE LAKE DR E STE 152
FRIDLEY MN
55432-5135
US

V. Phone/Fax

Practice location:
  • Phone: 612-389-2332
  • Fax: 612-389-2338
Mailing address:
  • Phone: 612-389-2332
  • Fax: 612-389-2338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANDREA PATTEN
Title or Position: DIRECTOR
Credential: LICSW
Phone: 612-389-2332