MEDICARE: EVERGLOW LANTERN MINDCARE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1871464248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGLOW LANTERN MINDCARE PLLC

Provider Business Mailing Address
First Line	:	1011 E MAIN ST STE 310A
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23219-3537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1011 E MAIN ST STE 310A
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23219-3537
Country	:	US
Telephone Number	:	305-542-9956
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VICTORIA ISABEL TAMAYO-MCHALE
Credential	:	PMHNP-BC
Telephone Number	:	305-542-9956

Provider Enumeration Date	:	09/17/2025
Last Update Date	:	09/17/2025

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