Healthcare Provider Details

I. General information

NPI: 1922753391
Provider Name (Legal Business Name): COLLECTIVE MINDS BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 05/04/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 BALTIMORE NATIONAL PIKE STE 304
BALTIMORE MD
21228-1410
US

IV. Provider business mailing address

5602 BALTIMORE NATIONAL PIKE STE 304
BALTIMORE MD
21228-1410
US

V. Phone/Fax

Practice location:
  • Phone: 410-804-9400
  • Fax:
Mailing address:
  • Phone: 410-804-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. IRA OWENS
Title or Position: OWNER
Credential:
Phone: 410-804-9400