MEDICARE: MINDFUL CONNECTIONS, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	SW8346	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639582661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL CONNECTIONS, LLC

Provider Business Mailing Address
First Line	:	733 NW 30TH CT
Second Line	:	UNIT # 7
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-2400
Country	:	US
Telephone Number	:	954-770-2363
Fax Number	:

Provider Business Practice Location Address
First Line	:	3042 N FEDERAL HWY
Second Line	:	SUITE 207
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33306-1400
Country	:	US
Telephone Number	:	954-770-2363
Fax Number	:

Authorized Official
Title or Position	:	OWNER / PRESIDENT
Name	:	BENJAMIN D GALLOSO
Credential	:	LCSW, CAP, ACHT
Telephone Number	:	954-770-2363

Provider Enumeration Date	:	06/06/2014
Last Update Date	:	06/06/2014

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Directions to “MINDFUL CONNECTIONS, LLC ” Practice Location

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