Healthcare Provider Details

I. General information

NPI: 1982310405
Provider Name (Legal Business Name): MINDSITE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6755 BUSINESS PKWY STE 109
ELKRIDGE MD
21075-6856
US

IV. Provider business mailing address

6755 BUSINESS PKWY STE 109
ELKRIDGE MD
21075-6856
US

V. Phone/Fax

Practice location:
  • Phone: 443-230-4050
  • Fax: 609-710-1599
Mailing address:
  • Phone: 443-230-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUSANA LYNN NWOUS
Title or Position: MEDICAL DIRECTOR
Credential: DNP, CRNP-PMH
Phone: 443-230-4050