MEDICARE: MAROLD MINDSET 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	106H00000X	Marriage & Family Therapist	613	CO

General Provider Information

NPI Number	:	1457453268
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAROLD MINDSET INC.

Provider Business Mailing Address
First Line	:	3120 BRADY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909-2125
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2864 S CIRCLE DR STE 350
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-4114
Country	:	US
Telephone Number	:	719-531-9211
Fax Number	:	719-540-6045

Authorized Official
Title or Position	:	OWNER
Name	:	MARION MAROLD VICKERMAN
Credential	:	LMFT
Telephone Number	:	719-660-4039

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	05/03/2013

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