MEDICARE: WOODHAVEN WELLNESS 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1124639190
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODHAVEN WELLNESS LLC

Provider Business Mailing Address
First Line	:	3000 CARRIAGE DR
Second Line	:
City	:	HAMEL
State	:	MN
Zip	:	55340-9597
Country	:	US
Telephone Number	:	763-478-7395
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 1ST AVE NE
Second Line	:
City	:	BUFFALO
State	:	MN
Zip	:	55313-1515
Country	:	US
Telephone Number	:	763-478-7395
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MARY G. MATTISON-WYNN
Credential	:	PSY.D.
Telephone Number	:	763-478-7395

Provider Enumeration Date	:	08/13/2020
Last Update Date	:	04/01/2021

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