=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285130633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MYND MATTERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2018
-----------------------------------------------------
Last Update Date | 04/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9201 ARBORETUM PKWY STE 110
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23236-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-320-0101
-----------------------------------------------------
Fax | 804-320-0808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9201 ARBORETUM PKWY STE 110
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23236-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-320-0101
-----------------------------------------------------
Fax | 804-320-0808
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID DAMERON
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 804-320-0101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------