Healthcare Provider Details

I. General information

NPI: 1558889857
Provider Name (Legal Business Name): MIND OVER MATTER HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 09/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 OLD EDMONDSON AVE. STE. 4
BALTIMORE MD
21228
US

IV. Provider business mailing address

616 OLD EDMONDSON AVE. STE. 4
BALTO MD
21228
US

V. Phone/Fax

Practice location:
  • Phone: 443-405-1095
  • Fax:
Mailing address:
  • Phone: 443-405-1095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberLC2133
License Number StateMD

VIII. Authorized Official

Name: ASIA MARIA JOHNSON
Title or Position: CEO
Credential: LCPC,ACS,LCAD-AS,MAC
Phone: 410-982-1353