Healthcare Provider Details

I. General information

NPI: 1285162016
Provider Name (Legal Business Name): MENDING MINDS COUNSELING AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 S COMMERCIAL ST
NEENAH WI
54956-4636
US

IV. Provider business mailing address

3155 HAYWARD AVE
OSHKOSH WI
54904-7446
US

V. Phone/Fax

Practice location:
  • Phone: 920-420-3188
  • Fax:
Mailing address:
  • Phone: 920-420-3188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2937-226
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number34629
License Number StateWI

VIII. Authorized Official

Name: SHARON A HANSEN
Title or Position: BEHAVIORAL HEALTH COUNSELOR
Credential: MSE
Phone: 920-420-3188