MEDICARE: MIND ABOVE MATTER 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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1629565189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIND ABOVE MATTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 1058
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76097-1058
Country	:	US
Telephone Number	:	817-447-3001
Fax Number	:	817-289-5623

Provider Business Practice Location Address
First Line	:	2400 E SEMINARY DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-5502
Country	:	US
Telephone Number	:	817-447-3001
Fax Number	:	817-289-5699

Authorized Official
Title or Position	:	BUSINESS OFFICE DIRECTOR
Name	:	MISTY MOLINA
Credential	:
Telephone Number	:	817-447-3001

Provider Enumeration Date	:	04/19/2018
Last Update Date	:	04/19/2018

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Directions to “MIND ABOVE MATTER LLC ” Practice Location

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