MEDICARE: INTEGRATIVE MINDFULNESS 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	103TC1900X	Counseling Psychologist	LP 0499	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1255305306	OTHER	MN	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1457630634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATIVE MINDFULNESS LLC

Provider Business Mailing Address
First Line	:	3608 44TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2906
Country	:	US
Telephone Number	:	612-872-9231
Fax Number	:	612-722-3306

Provider Business Practice Location Address
First Line	:	3608 44TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55406-2906
Country	:	US
Telephone Number	:	612-872-9231
Fax Number	:	612-722-3306

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	MS. KATHELEEN AVILA
Credential	:	M.A.
Telephone Number	:	612-872-9231

Provider Enumeration Date	:	08/05/2011
Last Update Date	:	08/05/2011

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