=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982391157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDFUL AND WELL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2023
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 E NORTH VILLAGE DR
-----------------------------------------------------
City | SHIPSHEWANA
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46565-8662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-383-2322
-----------------------------------------------------
Fax | 260-383-2422
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5955 N 1120 W
-----------------------------------------------------
City | MIDDLEBURY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46540-9386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-383-2322
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DORA MARTIN-EASH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 260-383-2322
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------