=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073879813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART MIND CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2012
-----------------------------------------------------
Last Update Date | 09/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28 WINDMILL RD
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87015-6918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-288-7025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28 WINDMILL RD
-----------------------------------------------------
City | EDGEWOOD
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87015-6918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-288-7025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL COUNSELOR
-----------------------------------------------------
Name | MELISSA A WOLF
-----------------------------------------------------
Credential | LPCC
-----------------------------------------------------
Telephone | 150-288-7025
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------