Provider Demographics
NPI:1013606326
Name:MINDFUL LEGACY LLC
Entity Type:Organization
Organization Name:MINDFUL LEGACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEKILA
Authorized Official - Middle Name:S
Authorized Official - Last Name:MELCHIOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:336-301-9765
Mailing Address - Street 1:12587 FAIR LAKES CIR # 406
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-3822
Mailing Address - Country:US
Mailing Address - Phone:336-301-9765
Mailing Address - Fax:
Practice Address - Street 1:4229 JEFFERSON OAKS CIR APT B
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-4071
Practice Address - Country:US
Practice Address - Phone:703-718-6413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-02
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty