MEDICARE: MINDOULA HEALTH INC.

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	251S00000X	Community/Behavioral Health Agency
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1154948180
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDOULA HEALTH INC.

Provider Business Mailing Address
First Line	:	8040 GEORGIA AVE STE 170
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20910-4959
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	232 CAPITOL ST
Second Line	:
City	:	CHARLESTON
State	:	WV
Zip	:	25301-2234
Country	:	US
Telephone Number	:	888-879-9786
Fax Number	:

Authorized Official
Title or Position	:	SVP OPERATIONS
Name	:	GREGORY COUTO
Credential	:
Telephone Number	:	954-650-2802

Provider Enumeration Date	:	06/25/2020
Last Update Date	:	01/11/2024

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