MEDICARE: MINDFUL PURPOSE-GUIDED COUNSELING SERVICES, 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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1578229738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL PURPOSE-GUIDED COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 33197
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76162-3197
Country	:	US
Telephone Number	:	817-229-8970
Fax Number	:

Provider Business Practice Location Address
First Line	:	7101 BRYANT IRVIN RD # 33197
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4135
Country	:	US
Telephone Number	:	817-229-8970
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	EBONY SKINNER
Credential	:
Telephone Number	:	817-229-8970

Provider Enumeration Date	:	11/11/2021
Last Update Date	:	11/11/2021

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