Healthcare Provider Details

I. General information

NPI: 1295332351
Provider Name (Legal Business Name): HEALING MINDS WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 PULASKI HWY
BALTIMORE MD
21224-1534
US

IV. Provider business mailing address

3600 PULASKI HWY
BALTIMORE MD
21224-1534
US

V. Phone/Fax

Practice location:
  • Phone: 443-961-7523
  • Fax:
Mailing address:
  • Phone: 443-961-7523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KENYONA DAVIS
Title or Position: CEO/PRESIDENT
Credential: LMSW
Phone: 443-961-7523