MEDICARE: MINDFUL RESTORATION COUNSELING, PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1720810211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL RESTORATION COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	4260 VICKSBURG TER
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-2314
Country	:	US
Telephone Number	:	406-598-5448
Fax Number	:

Provider Business Practice Location Address
First Line	:	4260 VICKSBURG TER
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-2314
Country	:	US
Telephone Number	:	406-598-5448
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHERYL LYNN HERNANDEZ-RUTZ
Credential	:	LCSW
Telephone Number	:	719-413-6880

Provider Enumeration Date	:	08/14/2024
Last Update Date	:	08/15/2024

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