=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336615202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL WAY COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2018
-----------------------------------------------------
Last Update Date | 09/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1250 MOORE LAKE DR E STE 152
-----------------------------------------------------
City | FRIDLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55432-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-389-2332
-----------------------------------------------------
Fax | 612-389-2338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 MOORE LAKE DR E STE 152
-----------------------------------------------------
City | FRIDLEY
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55432-5135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-389-2332
-----------------------------------------------------
Fax | 612-389-2338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ANDREA PATTEN
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 612-389-2332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------