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General NPI Number Information
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NPI Number | 1093289985
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Entity Type | Organization
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Legal Business Name | MIRROR MENTAL HEALTH
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Dates
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Enumeration Date | 01/14/2019
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Last Update Date | 01/14/2019
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Provider Practice Location Address
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Address Line | 2110 PRIEST BRIDGE DR STE 1
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City | CROFTON
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State | MD
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Zip | 21114-2472
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Country | US
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Telephone | 443-937-7089
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Fax | 443-292-4570
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Provider Business Mailing Address
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Address Line | 2110 PRIEST BRIDGE DR STE 1
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City | CROFTON
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State | MD
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Zip | 21114-2472
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Country | US
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Telephone | 443-937-7089
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Fax | 443-292-4570
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Authorized Official
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Title or Position | DIRECTOR, CREDENTIALING & CONTRACT
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Name | ANGIE BOULWARE
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Credential |
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Telephone | 800-288-3406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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