Healthcare Provider Details

I. General information

NPI: 1205525334
Provider Name (Legal Business Name): REVERED-HOLISTIC HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9861 BROKEN LAND PKWY STE 100
COLUMBIA MD
21046-3031
US

IV. Provider business mailing address

4518 RUNNYMEADE RD
OWINGS MILLS MD
21117-6156
US

V. Phone/Fax

Practice location:
  • Phone: 410-399-4240
  • Fax: 443-381-0216
Mailing address:
  • Phone: 410-399-4240
  • Fax: 443-381-0216

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 State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ADETUTU AWODIPE
Title or Position: PRESIDENT
Credential: PMHNP
Phone: 443-621-2203