Healthcare Provider Details

I. General information

NPI: 1871316919
Provider Name (Legal Business Name): MINDFUL PSYCHOTHERAPEUTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19847 JOHN J WILLIAMS HWY SUITE 213
REHOBOTH BEACH DE
19971
US

IV. Provider business mailing address

19847 JOHN J WILLIAMS HWY SUITE 213
REHOBOTH BEACH DE
19971
US

V. Phone/Fax

Practice location:
  • Phone: 302-827-3863
  • Fax:
Mailing address:
  • Phone: 302-827-3863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LARISSA TRELLES
Title or Position: OWNER/THERAPIST
Credential: LPCMH, NCC
Phone: 302-827-3863