MEDICARE: MINDVAULT HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	102L00000X	Psychoanalyst
2	104100000X	Social Worker
3	1041C0700X	Clinical Social Worker
4	101Y00000X	Counselor
5	101YA0400X	Addiction (Substance Use Disorder) Counselor
6	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1689321945
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDVAULT HEALTH, LLC

Provider Business Mailing Address
First Line	:	5541 E LAKE DR APT E
Second Line	:
City	:	LISLE
State	:	IL
Zip	:	60532-2679
Country	:	US
Telephone Number	:	630-384-9214
Fax Number	:

Provider Business Practice Location Address
First Line	:	5541 E LAKE DR APT E
Second Line	:
City	:	LISLE
State	:	IL
Zip	:	60532-2679
Country	:	US
Telephone Number	:	630-384-9214
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TODD MOKOS
Credential	:
Telephone Number	:	630-384-9214

Provider Enumeration Date	:	03/07/2022
Last Update Date	:	03/07/2022

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Directions to “MINDVAULT HEALTH, LLC ” Practice Location

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