MEDICARE: MENDING THE SOUL RESTORATION OF THE MIND BODY AND SOUL

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	:	1518610674
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MENDING THE SOUL RESTORATION OF THE MIND BODY AND SOUL

Provider Business Mailing Address
First Line	:	PO BOX 64594
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70896-4594
Country	:	US
Telephone Number	:	225-223-8252
Fax Number	:	225-208-1800

Provider Business Practice Location Address
First Line	:	3029 S SHERWOOD FOREST BLVD STE 205
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-2276
Country	:	US
Telephone Number	:	225-366-8766
Fax Number	:	225-208-1800

Authorized Official
Title or Position	:	OWNER
Name	:	SHONTELL BUFFINGTON
Credential	:	LCSW
Telephone Number	:	225-223-8252

Provider Enumeration Date	:	01/30/2022
Last Update Date	:	01/30/2022

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