Healthcare Provider Details

I. General information

NPI: 1467720565
Provider Name (Legal Business Name): MINDMENDER COUNSELING SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 12/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19824 W CATAWBA AVE SUITE G-205
CORNELIUS NC
28031-4046
US

IV. Provider business mailing address

PO BOX 2067
CORNELIUS NC
28031-2067
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-1828
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number3977
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1132
License Number StateNC

VIII. Authorized Official

Name: MS. COLLEEN MARY SERRENO
Title or Position: OWNER
Credential: LPC, LCAS
Phone: 704-892-1828