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General NPI Number Information
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NPI Number | 1053664110
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Entity Type | Organization
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Legal Business Name | PEACE OF MIND THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 10/25/2012
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Last Update Date | 10/25/2012
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Provider Practice Location Address
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Address Line | 1711 BRIGHTWELL CT
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City | WALDORF
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State | MD
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Zip | 20602-1634
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Country | US
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Telephone | 202-580-9029
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Fax | 301-850-1121
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Provider Business Mailing Address
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Address Line | 1711 BRIGHTWELL CT
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City | WALDORF
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State | MD
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Zip | 20602-1634
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Country | US
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Telephone | 202-580-9029
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Fax | 301-850-1121
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Authorized Official
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Title or Position | THERAPIST
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Name | MS. TEONNA L WALLOP
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Credential | LCPC, LPC
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Telephone | 301-850-1121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | PRC14226
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License Number State | DC
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | LC4121
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License Number State | MD
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