NPIMap

Organization Active NPI

Mirror Mental Health

  • Counseling Psychologist
  • Crofton, MD
National Provider Identifier
1093289985
Registry record updated Jan 14, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Counseling PsychologistTaxonomy code 103TC1900X
Legal business name
MIRROR MENTAL HEALTH
Practice address
2110 Priest Bridge Dr Ste 1
Crofton, MD 21114-2472
Phone
(443) 937-7089
Fax
(443) 292-4570
NPI assigned
Jan 14, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 14, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Angie Boulware
Title
Director, Credentialing & Contract
Phone
(800) 288-3406

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Counseling PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC1900X Primary

Addresses

Primary practice location

2110 Priest Bridge Dr Ste 1
Crofton, MD 21114-2472

Mailing address

2110 Priest Bridge Dr Ste 1
Crofton, MD 21114-2472
Phone (443) 937-7089

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190320001027 MD Part B Supplier - Clinic/Group Practice 6002156502 Receives reassigned benefits from 4 practitioners
Practice locations: Crofton, MD

National Provider Directory

National Provider Directory

Locations

2110 Priest Bridge Dr
Ste 1
Crofton, MD 21114
Phone (443) 937-7089

Practitioners & affiliated clinicians

Practitioners 23

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 23

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1547424000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547424000000",
    "number": "1093289985",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2110 PRIEST BRIDGE DR STE 1",
            "city": "CROFTON",
            "state": "MD",
            "postal_code": "211142472",
            "telephone_number": "443-937-7089",
            "fax_number": "443-292-4570"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2110 PRIEST BRIDGE DR STE 1",
            "city": "CROFTON",
            "state": "MD",
            "postal_code": "211142472",
            "telephone_number": "443-937-7089",
            "fax_number": "443-292-4570"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIRROR MENTAL HEALTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-01-14",
        "last_updated": "2019-01-14",
        "status": "A",
        "authorized_official_last_name": "BOULWARE",
        "authorized_official_first_name": "ANGIE",
        "authorized_official_title_or_position": "DIRECTOR, CREDENTIALING & CONTRACT",
        "authorized_official_telephone_number": "800-288-3406"
    },
    "taxonomies": [
        {
            "code": "103TC1900X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Counseling",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Crofton, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 14, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.