Healthcare Provider Details

I. General information

NPI: 1114584091
Provider Name (Legal Business Name): MENDING MINDS WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2019
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MERCANTILE LANE SUITE 485
LARGO MD
20774-2005
US

IV. Provider business mailing address

12138 CENTRAL AVE STE 937
MITCHELLVILLE MD
20721-1910
US

V. Phone/Fax

Practice location:
  • Phone: 301-615-1911
  • Fax:
Mailing address:
  • Phone: 240-484-7112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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: MS. JENE COLETTE GOULD
Title or Position: PSYHOTHERAPIST
Credential: LCSW-C
Phone: 301-615-1911