MEDICARE: MIDWEST MENTAL HEALTH 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	077004	IA

General Provider Information

NPI Number	:	1144695040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	PO BOX 115
Second Line	:
City	:	SHENANDOAH
State	:	IA
Zip	:	51601-0115
Country	:	US
Telephone Number	:	712-246-0159
Fax Number	:

Provider Business Practice Location Address
First Line	:	523 W SHERIDAN AVE
Second Line	:
City	:	SHENANDOAH
State	:	IA
Zip	:	51601-1705
Country	:	US
Telephone Number	:	712-246-0159
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MENTAL HEALTH COUNSELOR
Name	:	KINDRA ANISA WESTON
Credential	:	M.S., LMHC, NCC
Telephone Number	:	712-350-3771

Provider Enumeration Date	:	12/03/2015
Last Update Date	:	12/03/2015

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