Healthcare Provider Details

I. General information

NPI: 1023937174
Provider Name (Legal Business Name): MINDFUL PRACTICE CO. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E REAGAN PKWY
MEDINA OH
44256-1238
US

IV. Provider business mailing address

PO BOX 100
MEDINA OH
44258-0100
US

V. Phone/Fax

Practice location:
  • Phone: 614-285-4827
  • Fax:
Mailing address:
  • Phone: 614-285-4827
  • Fax:

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: KATELYN WAGNER
Title or Position: OWNER/MENTAL HEALTH THERAPIST
Credential: LISW-S
Phone: 614-285-4827