Healthcare Provider Details

I. General information

NPI: 1396441416
Provider Name (Legal Business Name): RENEW YOUR MIND WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 06/29/2024
Certification Date: 06/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 TWIN KNOLLS RD STE 107
COLUMBIA MD
21045-3260
US

IV. Provider business mailing address

9091 SNOWDEN RIVER PKWY # 1316
COLUMBIA MD
21046-1657
US

V. Phone/Fax

Practice location:
  • Phone: 443-690-2272
  • Fax: 855-450-1084
Mailing address:
  • Phone: 443-690-2272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KATIA COLEY
Title or Position: ADMIN/PROVIDER
Credential:
Phone: 240-350-3015