MEDICARE: MINDFUL THERAPY & WELLNESS, 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1811605470
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINDFUL THERAPY & WELLNESS, PLLC

Provider Business Mailing Address
First Line	:	5332 W WINDSOR AVE UNIT 2B
Second Line	:	C/O DIANE TARCHALA
City	:	CHICAGO
State	:	IL
Zip	:	60630-3138
Country	:	US
Telephone Number	:	773-203-5374
Fax Number	:

Provider Business Practice Location Address
First Line	:	655 W IRVING PARK RD APT 4817
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60613-3138
Country	:	US
Telephone Number	:	773-203-5374
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PSYCHOTHERAPIST
Name	:	DEVIN WILLIAM BERCAW
Credential	:	LCPC
Telephone Number	:	773-203-5374

Provider Enumeration Date	:	11/11/2022
Last Update Date	:	05/31/2024

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