Healthcare Provider Details

I. General information

NPI: 1609449677
Provider Name (Legal Business Name): LIGHT AND MIND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 01/25/2025
Certification Date: 01/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8707 COMMERCE DR STE E
EASTON MD
21601-6910
US

IV. Provider business mailing address

8707 COMMERCE DR STE E
EASTON MD
21601-6910
US

V. Phone/Fax

Practice location:
  • Phone: 410-855-4664
  • Fax: 855-461-3481
Mailing address:
  • Phone: 443-239-2033
  • Fax: 855-461-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AISHA HASSAN-DAVIS
Title or Position: OWNER/PROVIDER
Credential: CNS,PMH-NP, APRN
Phone: 443-239-2033