Healthcare Provider Details

I. General information

NPI: 1619612686
Provider Name (Legal Business Name): MINDFUL HEALING GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 CHAIN BRIDGE RD STE 302
MC LEAN VA
22101-4501
US

IV. Provider business mailing address

8601 LARKHAVEN TER
FAIRFAX STATION VA
22039-3313
US

V. Phone/Fax

Practice location:
  • Phone: 703-987-6500
  • Fax: 240-219-3138
Mailing address:
  • Phone: 571-435-3334
  • Fax: 240-219-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KELLY RANKIN
Title or Position: PRACTICE MANAGER
Credential: LCSW
Phone: 703-987-6500