Provider Demographics
NPI:1912452327
Name:MINDSHAPE LLC
Entity type:Organization
Organization Name:MINDSHAPE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPIVACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-841-1290
Mailing Address - Street 1:2501 N GLEBE RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22207-3558
Mailing Address - Country:US
Mailing Address - Phone:703-841-1290
Mailing Address - Fax:703-841-1315
Practice Address - Street 1:2960 SLEEPY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22044-2030
Practice Address - Country:US
Practice Address - Phone:703-536-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-16
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty