Provider Demographics
NPI:1114599958
Name:MIND MELD PSYCHOTHERAPY PLLC
Entity Type:Organization
Organization Name:MIND MELD PSYCHOTHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER MMP
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:OSO
Authorized Official - Last Name:ENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:804-409-7525
Mailing Address - Street 1:3530 N COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-3408
Mailing Address - Country:US
Mailing Address - Phone:804-409-7525
Mailing Address - Fax:804-315-9380
Practice Address - Street 1:3530 N COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:PROVIDENCE FORGE
Practice Address - State:VA
Practice Address - Zip Code:23140-3408
Practice Address - Country:US
Practice Address - Phone:804-409-7525
Practice Address - Fax:804-315-9380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-12
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty