Provider Demographics
NPI:1841976016
Name:MIRROR MENTAL HEALTH AND WELLNESS
Entity type:Organization
Organization Name:MIRROR MENTAL HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNDIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-351-0740
Mailing Address - Street 1:151 W COMMERCE RD APT 211
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-2372
Mailing Address - Country:US
Mailing Address - Phone:773-354-1531
Mailing Address - Fax:
Practice Address - Street 1:306 TURNER RD STE A
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23225-6432
Practice Address - Country:US
Practice Address - Phone:773-351-0740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty