Provider Demographics
NPI:1003493610
Name:MODERN MIND THERAPY & LIFE COACHING LLC
Entity Type:Organization
Organization Name:MODERN MIND THERAPY & LIFE COACHING LLC
Other - Org Name:MODERN MIND THERAPY & LIFE COACHING LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAKEISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAYER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-303-7808
Mailing Address - Street 1:13645 LEGACY CIR APT A
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-5265
Mailing Address - Country:US
Mailing Address - Phone:175-730-3780
Mailing Address - Fax:
Practice Address - Street 1:4601 FAIRFAX DR STE 1200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22203-1559
Practice Address - Country:US
Practice Address - Phone:757-303-7808
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-28
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1467077651OtherNPI