Healthcare Provider Details

I. General information

NPI: 1215841804
Provider Name (Legal Business Name): MENTALLY EVOLVED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST RD STE 300
TOWSON MD
21204-2370
US

IV. Provider business mailing address

100 WEST RD STE 300 PMB 17673455
TOWSON MD
21204-2370
US

V. Phone/Fax

Practice location:
  • Phone: 410-832-7000
  • Fax:
Mailing address:
  • Phone: 443-939-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. TYIES ALEXANDER GOINES
Title or Position: CRNP-PMH
Credential: MSN, CRNP-PMH
Phone: 443-939-4422