=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972268043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I AM A MIND HEALER WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2021
-----------------------------------------------------
Last Update Date | 11/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 DEMOCRACY CIR APT 204
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-8147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-300-5289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2769 JEFFERSON DAVIS HWY STE 111-1098
-----------------------------------------------------
City | STAFFORD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22554-8325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-300-5289
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PROFESSIONAL COUNSELOR
-----------------------------------------------------
Name | MS. PAMELA BROWN
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 703-867-2565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------