Healthcare Provider Details

I. General information

NPI: 1003757790
Provider Name (Legal Business Name): MINDBLOOM PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2026
Last Update Date: 04/04/2026
Certification Date: 04/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7480 BIRDWOOD AVE
MC LEAN VA
22102-7405
US

IV. Provider business mailing address

7480 BIRDWOOD AVE
MC LEAN VA
22102-7405
US

V. Phone/Fax

Practice location:
  • Phone: 571-306-0601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: FRANCA BAKANE
Title or Position: OWNER
Credential: PMHNP-BC
Phone: 571-306-0601