=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104509710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL CONNECTIONS COUNSELING AND LEARNING CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2023
-----------------------------------------------------
Last Update Date | 08/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3509 E SHEA BLVD STE 111
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85028-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-808-9535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3509 E SHEA BLVD STE 111
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85028-3338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-808-9535
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CLINICAL DIRECTOR
-----------------------------------------------------
Name | MERYL WARDA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 480-818-1561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------