Healthcare Provider Details

I. General information

NPI: 1821773615
Provider Name (Legal Business Name): MINDFUL THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 OLD COURT RD STE 204
RANDALLSTOWN MD
21133-6201
US

IV. Provider business mailing address

4104 KIWI CT
RANDALLSTOWN MD
21133-4076
US

V. Phone/Fax

Practice location:
  • Phone: 410-977-5100
  • Fax:
Mailing address:
  • Phone: 410-977-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: KELLY MONIQUE TURNER WOOLFORD
Title or Position: OWNER
Credential: LCPC
Phone: 410-997-5100