Provider Demographics
NPI:1043462757
Name:MIND RENEWAL COUNSELING & COACHING, LLC
Entity Type:Organization
Organization Name:MIND RENEWAL COUNSELING & COACHING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORAKER
Authorized Official - Suffix:
Authorized Official - Credentials:ABD, LMHC, NCC
Authorized Official - Phone:561-366-9111
Mailing Address - Street 1:224 DATURA ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33401-5624
Mailing Address - Country:US
Mailing Address - Phone:561-366-9111
Mailing Address - Fax:561-366-9119
Practice Address - Street 1:224 DATURA ST
Practice Address - Street 2:SUITE 407
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-5624
Practice Address - Country:US
Practice Address - Phone:561-366-9111
Practice Address - Fax:561-366-9119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7843101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty