Healthcare Provider Details

I. General information

NPI: 1902423114
Provider Name (Legal Business Name): MINDFUL ONE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2020
Last Update Date: 07/03/2020
Certification Date: 07/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5921 HALL ST
SPRINGFIELD VA
22152-1402
US

IV. Provider business mailing address

5921 HALL ST
SPRINGFIELD VA
22152-1402
US

V. Phone/Fax

Practice location:
  • Phone: 571-332-9095
  • Fax:
Mailing address:
  • Phone: 571-332-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MALA K TANDON
Title or Position: DIRECTOR
Credential: PSY.D
Phone: 571-332-9095