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General NPI Number Information
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NPI Number | 1003493610
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Entity Type | Organization
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Legal Business Name | MODERN MIND THERAPY & LIFE COACHING LLC
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Dates
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Enumeration Date | 03/28/2021
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Last Update Date | 04/05/2021
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Provider Practice Location Address
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Address Line | 4601 FAIRFAX DR STE 1200
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City | ARLINGTON
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State | VA
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Zip | 22203-1559
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Country | US
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Telephone | 757-303-7808
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Fax |
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Provider Business Mailing Address
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Address Line | 13645 LEGACY CIR APT A
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City | HERNDON
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State | VA
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Zip | 20171-5265
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Country | US
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Telephone | 175-730-3780
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LAKEISHA GRAYER
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Credential | LPC
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Telephone | 757-303-7808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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