Provider Demographics
NPI:1255097838
Name:REFLECTIVE MINDS MENTAL WELLNESS, LLC
Entity type:Organization
Organization Name:REFLECTIVE MINDS MENTAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:CRNP-PMH
Authorized Official - Phone:803-261-2342
Mailing Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3231
Mailing Address - Country:US
Mailing Address - Phone:301-478-8609
Mailing Address - Fax:
Practice Address - Street 1:3261 OLD WASHINGTON RD STE 2020
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3231
Practice Address - Country:US
Practice Address - Phone:301-478-8609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-09
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty