MEDICARE: MIND IN BALANCE, 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	101YP2500X	Professional Counselor	62628	TX

General Provider Information

NPI Number	:	1619384757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND IN BALANCE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 542781
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-2781
Country	:	US
Telephone Number	:	214-417-7803
Fax Number	:	888-965-6186

Provider Business Practice Location Address
First Line	:	2300 VALLEY VIEW LN STE 237
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-5014
Country	:	US
Telephone Number	:	214-417-7803
Fax Number	:	888-965-6186

Authorized Official
Title or Position	:	OWNER, COUNSELOR
Name	:	JOLENE C. MCVEAN
Credential	:	M.ED., LPC
Telephone Number	:	214-417-7803

Provider Enumeration Date	:	07/21/2014
Last Update Date	:	07/21/2014

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Directions to “MIND IN BALANCE, LLC ” Practice Location

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