MEDICARE: MIND RENEWAL PSYCHOTHERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	1041C0700X	Clinical Social Worker
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
4	261QM0855X	Adolescent and Children Mental Health Clinic/Center
5	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1558185157
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND RENEWAL PSYCHOTHERAPY

Provider Business Mailing Address
First Line	:	5464 N PORT WASHINGTON RD # C104
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53217-4925
Country	:	US
Telephone Number	:	414-301-3145
Fax Number	:

Provider Business Practice Location Address
First Line	:	6650 W STATE ST UNIT D143
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-2827
Country	:	US
Telephone Number	:	414-301-3145
Fax Number	:	414-296-0093

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY HOWARD
Credential	:
Telephone Number	:	414-301-3145

Provider Enumeration Date	:	11/11/2024
Last Update Date	:	04/29/2025

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1780327924 — MS. SARAH LUECKE
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