Healthcare Provider Details

I. General information

NPI: 1003565979
Provider Name (Legal Business Name): MIND OVER MATTER HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2022
Last Update Date: 03/19/2022
Certification Date: 03/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10016 MARRIOTTSVILLE RD
RANDALLSTOWN MD
21133-1502
US

IV. Provider business mailing address

10016 MARRIOTTSVILLE RD
RANDALLSTOWN MD
21133-1502
US

V. Phone/Fax

Practice location:
  • Phone: 443-405-1095
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ASIA JOHNSON
Title or Position: PRACTITIONER/ADMINISTRATOR
Credential: LCPC
Phone: 410-982-1353