Provider Demographics
NPI:1851151427
Name:MINDFUL CHI BEHAVIORAL HEALTH, INC.
Entity Type:Organization
Organization Name:MINDFUL CHI BEHAVIORAL HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN-LARE
Authorized Official - Suffix:
Authorized Official - Credentials:DMSC
Authorized Official - Phone:678-907-3060
Mailing Address - Street 1:5457 TWIN KNOLLS RD
Mailing Address - Street 2:STE 300 #1082
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5457 TWIN KNOLLS RD
Practice Address - Street 2:STE 300 #1082
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3296
Practice Address - Country:US
Practice Address - Phone:240-608-2744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty