Healthcare Provider Details

I. General information

NPI: 1780514901
Provider Name (Legal Business Name): MINDFULLY ROOTED COLLABORATIVE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10770 COLUMBIA PIKE STE 300
SILVER SPRING MD
20901-4439
US

IV. Provider business mailing address

10770 COLUMBIA PIKE STE 300
SILVER SPRING MD
20901-4439
US

V. Phone/Fax

Practice location:
  • Phone: 857-312-3687
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: TACIA COLON-JOHNSON
Title or Position: CLINICAL SOCIAL WORKER/OWNER
Credential: LCSW-C
Phone: 857-312-3687