Provider Demographics
NPI:1407359268
Name:MINDFUL MARRIAGE AND FAMILY THERAPY, LLC
Entity Type:Organization
Organization Name:MINDFUL MARRIAGE AND FAMILY THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LESLEE
Authorized Official - Middle Name:SOPHIA
Authorized Official - Last Name:BRY
Authorized Official - Suffix:
Authorized Official - Credentials:LCMFT
Authorized Official - Phone:301-514-8120
Mailing Address - Street 1:5257 BUCKEYSTOWN PIKE # 123
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21704-7535
Mailing Address - Country:US
Mailing Address - Phone:301-514-8120
Mailing Address - Fax:
Practice Address - Street 1:2502 URBANA PIKE
Practice Address - Street 2:
Practice Address - City:IJAMSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21754-8602
Practice Address - Country:US
Practice Address - Phone:301-281-4963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCM570261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)