Provider Demographics
NPI:1467104844
Name:MINDFUL ATHLETES
Entity Type:Organization
Organization Name:MINDFUL ATHLETES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KAILYN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-220-0037
Mailing Address - Street 1:12569 PLYMOUTH CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2349
Mailing Address - Country:US
Mailing Address - Phone:703-220-0037
Mailing Address - Fax:
Practice Address - Street 1:12569 PLYMOUTH CT
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2349
Practice Address - Country:US
Practice Address - Phone:703-220-0037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2123OtherANTHEM