Healthcare Provider Details

I. General information

NPI: 1316865355
Provider Name (Legal Business Name): MINDSPACE INTEGRATED CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5290 SHAWNEE RD
ALEXANDRIA VA
22312-2381
US

IV. Provider business mailing address

4203 VERNOY HILLS CMN
FAIRFAX VA
22033-4399
US

V. Phone/Fax

Practice location:
  • Phone: 571-265-5969
  • Fax:
Mailing address:
  • Phone: 571-265-5969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. FATMATA SORIE KAMARA
Title or Position: PMHNP
Credential:
Phone: 571-265-5969