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General NPI Number Information
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NPI Number | 1366116477
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Entity Type | Organization
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Legal Business Name | MINDFUL MOMENTUM COUNSELING PLLC
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Dates
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Enumeration Date | 08/03/2021
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Last Update Date | 09/14/2021
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Provider Practice Location Address
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Address Line | 132 W LAKE ST OFC 4
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1020
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Country | US
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Telephone | 847-773-1684
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Fax |
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Provider Business Mailing Address
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Address Line | 435 W SHADY LANE RD
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City | PALATINE
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State | IL
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Zip | 60074-1066
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Country | US
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Telephone | 847-773-1684
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. JOSEPH RUBIN
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Credential | LCPC
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Telephone | 847-773-1684
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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