Healthcare Provider Details

I. General information

NPI: 1588309314
Provider Name (Legal Business Name): SHIFTING MINDSETS COUNSELING AND CONSULTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10530 CAMPUS WAY S # 1143
LARGO MD
20774-1309
US

IV. Provider business mailing address

3508 COMMUNITY DR
DISTRICT HEIGHTS MD
20747-5902
US

V. Phone/Fax

Practice location:
  • Phone: 443-497-8799
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MARCELLINA FUQUA
Title or Position: C.E.O
Credential: LCSW-C
Phone: 443-497-8799