Healthcare Provider Details

I. General information

NPI: 1407638687
Provider Name (Legal Business Name): MIND-4-CONCEPTS OUTPATIENT MENTAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N CHARLES ST STE 508
BALTIMORE MD
21201-5920
US

IV. Provider business mailing address

1800 N CHARLES ST STE 508
BALTIMORE MD
21201-5920
US

V. Phone/Fax

Practice location:
  • Phone: 410-801-8828
  • Fax: 443-817-0863
Mailing address:
  • Phone: 410-801-8828
  • Fax: 443-817-0863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. MICHELLE GILLIAM
Title or Position: CEO
Credential:
Phone: 410-801-8828