Healthcare Provider Details

I. General information

NPI: 1700565652
Provider Name (Legal Business Name): VITAL MIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2023
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 EASTERN AVE STE B3
FAIRMOUNT HEIGHTS MD
20743-1677
US

IV. Provider business mailing address

525 EASTERN AVE STE B3
FAIRMOUNT HEIGHTS MD
20743-1677
US

V. Phone/Fax

Practice location:
  • Phone: 703-980-0478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: EBUNOLUWA LAWAL
Title or Position: CEO
Credential:
Phone: 703-980-0478