MEDICARE: MINDFUL MOMENTUM, 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1497548994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL MOMENTUM, LLC

Provider Business Mailing Address
First Line	:	313 WINDELL DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-6526
Country	:	US
Telephone Number	:	803-250-1375
Fax Number	:

Provider Business Practice Location Address
First Line	:	313 WINDELL DR
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-6526
Country	:	US
Telephone Number	:	803-250-1375
Fax Number	:

Authorized Official
Title or Position	:	PROFESSIONAL COUNSELOR-ASSOCIATE
Name	:	MRS. MARLA J. MCKENZIE
Credential	:	LPCA
Telephone Number	:	803-250-1375

Provider Enumeration Date	:	05/27/2025
Last Update Date	:	06/06/2025

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