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General NPI Number Information
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NPI Number | 1841976016
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Entity Type | Organization
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Legal Business Name | MIRROR MENTAL HEALTH AND WELLNESS
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Dates
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Enumeration Date | 06/23/2023
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Last Update Date | 06/23/2023
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Provider Practice Location Address
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Address Line | 306 TURNER RD STE A
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23225-6432
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Country | US
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Telephone | 773-351-0740
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Fax |
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Provider Business Mailing Address
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Address Line | 151 W COMMERCE RD APT 211
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City | RICHMOND
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State | VA
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Zip | 23224-2372
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Country | US
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Telephone | 773-354-1531
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. JENNIFER BRUNDIDGE
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Credential |
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Telephone | 773-351-0740
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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