Provider Demographics
NPI:1114584091
Name:MENDING MINDS WELLNESS CENTER
Entity Type:Organization
Organization Name:MENDING MINDS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYHOTHERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JENE
Authorized Official - Middle Name:COLETTE
Authorized Official - Last Name:GOULD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-C
Authorized Official - Phone:301-615-1911
Mailing Address - Street 1:12138 CENTRAL AVE STE 937
Mailing Address - Street 2:
Mailing Address - City:MITCHELLVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-1910
Mailing Address - Country:US
Mailing Address - Phone:240-484-7112
Mailing Address - Fax:
Practice Address - Street 1:1401 MERCANTILE LANE
Practice Address - Street 2:SUITE 485
Practice Address - City:LARGO
Practice Address - State:MD
Practice Address - Zip Code:20774-2005
Practice Address - Country:US
Practice Address - Phone:301-615-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-25
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty