Healthcare Provider Details

I. General information

NPI: 1023791258
Provider Name (Legal Business Name): WISE MIND BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 12/28/2025
Certification Date: 12/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 THOMAS JOHNSON DR STE 204
FREDERICK MD
21702-4538
US

IV. Provider business mailing address

176 THOMAS JOHNSON DR
FREDERICK MD
21702-4410
US

V. Phone/Fax

Practice location:
  • Phone: 240-608-2307
  • Fax:
Mailing address:
  • Phone: 240-608-2307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW GOODWIN
Title or Position: OWNER
Credential: LCPC
Phone: 240-608-2307