Provider Demographics
NPI:1437027315
Name:MIMO BACKFIN BLUES
Entity type:Organization
Organization Name:MIMO BACKFIN BLUES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LULA
Authorized Official - Middle Name:MOULTRIE
Authorized Official - Last Name:HEATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, MRC, LCSW-C
Authorized Official - Phone:240-273-8062
Mailing Address - Street 1:500 EDGEWOOD RD STE 202
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-2734
Mailing Address - Country:US
Mailing Address - Phone:443-967-4656
Mailing Address - Fax:443-449-7573
Practice Address - Street 1:500 EDGEWOOD RD STE 202
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-2734
Practice Address - Country:US
Practice Address - Phone:443-967-4656
Practice Address - Fax:443-449-7573
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESILIENCE ACADEMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-10-23
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty