Healthcare Provider Details

I. General information

NPI: 1093469231
Provider Name (Legal Business Name): MJB HOLISTIC AND THERAPEUTIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 MERCANTILE LN STE 129-14
UPPER MARLBORO MD
20774-5327
US

IV. Provider business mailing address

1300 MERCANTILE LN STE 129-14
UPPER MARLBORO MD
20774-5327
US

V. Phone/Fax

Practice location:
  • Phone: 301-381-3622
  • Fax:
Mailing address:
  • Phone: 301-381-3622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELVEENA JOHNSON-BOLDEN
Title or Position: CEO/NURSE PRACTITIONER
Credential: PMHNP-BC
Phone: 240-301-1034