MEDICARE: MINDFUL WAY COUNSELING, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	106H00000X	Marriage & Family Therapist
2	101YA0400X	Addiction (Substance Use Disorder) Counselor
3	101YP2500X	Professional Counselor
4	103TC0700X	Clinical Psychologist
5	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1336615202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL WAY COUNSELING, LLC

Provider Business Mailing Address
First Line	:	1250 MOORE LAKE DR E STE 152
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5135
Country	:	US
Telephone Number	:	612-389-2332
Fax Number	:	612-389-2338

Provider Business Practice Location Address
First Line	:	1250 MOORE LAKE DR E STE 152
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55432-5135
Country	:	US
Telephone Number	:	612-389-2332
Fax Number	:	612-389-2338

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ANDREA PATTEN
Credential	:	LICSW
Telephone Number	:	612-389-2332

Provider Enumeration Date	:	10/18/2018
Last Update Date	:	09/20/2019

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