=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366066938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND HEART CONNECTION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2020
-----------------------------------------------------
Last Update Date | 05/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 820 MAPLE FOREST CT
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-7566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-295-1968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 820 MAPLE FOREST CT
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-7566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-295-1968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGISTERED AGENT
-----------------------------------------------------
Name | MR. MARK THOMAS BLEIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-295-1968
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------