MEDICARE: MINDESCAPE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101Y00000X	Counselor
2	235Z00000X	Speech-Language Pathologist
3	225X00000X	Occupational Therapist
4	101YM0800X	Mental Health Counselor
5	103T00000X	Psychologist
6	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1760216915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDESCAPE LLC

Provider Business Mailing Address
First Line	:	27911 CROWN LAKE BLVD
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-4210
Country	:	US
Telephone Number	:	800-861-1403
Fax Number	:	800-861-1403

Provider Business Practice Location Address
First Line	:	27911 CROWN LAKE BLVD
Second Line	:
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34135-4210
Country	:	US
Telephone Number	:	800-961-3367
Fax Number	:	800-961-3367

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MAVELYN MILLARD
Credential	:
Telephone Number	:	800-681-1403

Provider Enumeration Date	:	08/29/2024
Last Update Date	:	03/10/2026

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Directions to “MINDESCAPE LLC ” Practice Location

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