Healthcare Provider Details

I. General information

NPI: 1558296335
Provider Name (Legal Business Name): ELEVATED MINDSET THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CHURCH ST NE STE 212
VIENNA VA
22180-4734
US

IV. Provider business mailing address

11730 INDIAN RIDGE RD
RESTON VA
20191-3522
US

V. Phone/Fax

Practice location:
  • Phone: 571-230-4205
  • Fax:
Mailing address:
  • Phone: 571-230-4205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DANIEL LAVELLE
Title or Position: OWNER
Credential: LPC
Phone: 571-230-4205