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Organization
MINDFUL ATHLETES
Active
Organization
MINDFUL ATHLETES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KAILYN RAE SLADE LCSW (LICENSED CLINICAL SOCIAL WORKER)
(703) 220-0037
Entity
Organization
Contact information
Practice address
12569 PLYMOUTH CT, WOODBRIDGE, VA 22192-2349
(703) 220-0037
Mailing address
12569 PLYMOUTH CT, WOODBRIDGE, VA 22192-2349
(703) 220-0037
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2123
ANTHEM
VA
Enumeration date
01/26/2022
Last updated
01/26/2022
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