MEDICARE: MIND RENEWAL COUNSELING & COACHING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH7843	FL

General Provider Information

NPI Number	:	1043462757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND RENEWAL COUNSELING & COACHING, LLC

Provider Business Mailing Address
First Line	:	224 DATURA ST
Second Line	:	SUITE 407
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5624
Country	:	US
Telephone Number	:	561-366-9111
Fax Number	:	561-366-9119

Provider Business Practice Location Address
First Line	:	224 DATURA ST
Second Line	:	SUITE 407
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33401-5624
Country	:	US
Telephone Number	:	561-366-9111
Fax Number	:	561-366-9119

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MICHELLE A FORAKER
Credential	:	ABD, LMHC, NCC
Telephone Number	:	561-366-9111

Provider Enumeration Date	:	10/14/2008
Last Update Date	:	10/14/2008

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