MEDICARE: MINDFUL HEALING THERAPY AND 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	261QD1600X	Developmental Disabilities Clinic/Center	SW14306	FL
2	261QM0850X	Adult Mental Health Clinic/Center	SW14306	FL
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center	SW14306	FL
4	101YM0800X	Mental Health Counselor	SW14306	FL

General Provider Information

NPI Number	:	1366968554
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL HEALING THERAPY AND WELLNESS, LLC

Provider Business Mailing Address
First Line	:	400 E DR MARTIN LUTHER KING JR BLVD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-3866
Country	:	US
Telephone Number	:	813-236-4673
Fax Number	:	813-236-4689

Provider Business Practice Location Address
First Line	:	400 E DR MARTIN LUTHER KING JR BLVD STE 101
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-3866
Country	:	US
Telephone Number	:	813-236-4673
Fax Number	:	813-236-4689

Authorized Official
Title or Position	:	OWNER, PSYCHOTHERAPIST
Name	:	MS. JESSICA R GREAVES
Credential	:	MSW, LCSW
Telephone Number	:	813-505-6867

Provider Enumeration Date	:	08/18/2017
Last Update Date	:	07/21/2022

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