MEDICARE: MINDFUL LIFE PRACTICE, 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	6401009566	MI
2	1041C0700X	Clinical Social Worker	6801093556	MI
3	1041C0700X	Clinical Social Worker	6801092522	MI

General Provider Information

NPI Number	:	1053781765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL LIFE PRACTICE, LLC

Provider Business Mailing Address
First Line	:	221 GARLAND ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2372
Country	:	US
Telephone Number	:	231-486-0805
Fax Number	:

Provider Business Practice Location Address
First Line	:	221 GARLAND ST
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-2372
Country	:	US
Telephone Number	:	231-486-0805
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	LINDA SMITH
Credential	:	LMSW
Telephone Number	:	231-486-0805

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	01/17/2025

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