MEDICARE: MINDFUL ROOTS COUNSELING, 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	:	1558952184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL ROOTS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	408 ELM ST
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-3131
Country	:	US
Telephone Number	:	724-599-4060
Fax Number	:

Provider Business Practice Location Address
First Line	:	647 PHILADELPHIA ST STE 303
Second Line	:
City	:	INDIANA
State	:	PA
Zip	:	15701-3923
Country	:	US
Telephone Number	:	724-599-4060
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PROFESSIONAL COUNSELOR
Name	:	NICHOLAS JACOB MATALIK
Credential	:
Telephone Number	:	724-599-4060

Provider Enumeration Date	:	01/27/2021
Last Update Date	:	01/27/2021

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