Healthcare Provider Details

I. General information

NPI: 1437911336
Provider Name (Legal Business Name): REACHING YOUR DESTINY WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4327 HARFORD RD STE 2
BALTIMORE MD
21214-3184
US

IV. Provider business mailing address

2206 WESTFIELD AVE
BALTIMORE MD
21214-1050
US

V. Phone/Fax

Practice location:
  • Phone: 410-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name: MS. DELISA PROCKS
Title or Position: PHD
Credential:
Phone: 410-999-9999