Healthcare Provider Details

I. General information

NPI: 1366879512
Provider Name (Legal Business Name): MINDFUL BEHAVIORAL OF MARYLAND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 10/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 PARKWAY
CHEVERLY MD
20785-1256
US

IV. Provider business mailing address

3109 PARKWAY
CHEVERLY MD
20785-1256
US

V. Phone/Fax

Practice location:
  • Phone: 919-697-0767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AKILA PROCTOR
Title or Position: PRESIDENT
Credential:
Phone: 919-697-0767