=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457825606
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENDING MINDS, HEALING HEARTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2019
-----------------------------------------------------
Last Update Date | 01/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 536 MAPLE AVE
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-703-7849
-----------------------------------------------------
Fax | 609-904-5543
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 536 MAPLE AVE
-----------------------------------------------------
City | LINWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08221-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-703-7849
-----------------------------------------------------
Fax | 609-904-5543
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, DIRECTOR
-----------------------------------------------------
Name | KATHERINE C MATTLEMAN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 609-703-7849
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------