Healthcare Provider Details

I. General information

NPI: 1497261481
Provider Name (Legal Business Name): MINDFULNESS AND CHANGE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SPRING ST STE 215
WATERTOWN MA
02472-3474
US

IV. Provider business mailing address

40 SPRING ST STE 215
WATERTOWN MA
02472-3474
US

V. Phone/Fax

Practice location:
  • Phone: 617-690-9645
  • Fax: 844-238-9457
Mailing address:
  • Phone:
  • Fax: 844-238-9457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER SOLODYNA
Title or Position: EXECUTIVE DIRECTOR/FOUNDER
Credential: PSYD
Phone: 617-690-9645