Healthcare Provider Details

I. General information

NPI: 1851071047
Provider Name (Legal Business Name): MINDWELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2023
Last Update Date: 07/21/2023
Certification Date: 07/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 QUIVERS KEEP
CHESAPEAKE VA
23321-1438
US

IV. Provider business mailing address

1821 QUIVERS KEEP
CHESAPEAKE VA
23321-1438
US

V. Phone/Fax

Practice location:
  • Phone: 757-577-5857
  • Fax:
Mailing address:
  • Phone: 757-577-5857
  • 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 Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. HOLLY DUCKETT
Title or Position: OWNER
Credential: PHD
Phone: 757-577-5857