Provider Demographics
NPI:1285162016
Name:MENDING MINDS COUNSELING AND WELLNESS LLC
Entity type:Organization
Organization Name:MENDING MINDS COUNSELING AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:A
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSE
Authorized Official - Phone:920-420-3188
Mailing Address - Street 1:3155 HAYWARD AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7446
Mailing Address - Country:US
Mailing Address - Phone:920-420-3188
Mailing Address - Fax:
Practice Address - Street 1:1370 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-4636
Practice Address - Country:US
Practice Address - Phone:920-420-3188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-24
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2937-226101YM0800X
WI34629101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100055261Medicaid