Healthcare Provider Details

I. General information

NPI: 1508297292
Provider Name (Legal Business Name): HER MIND HER BODY WELLNESS PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 LORD BALTIMORE DR STE 202
WINDSOR MILL MD
21244-5802
US

IV. Provider business mailing address

3104 LORD BALTIMORE DR STE 202
WINDSOR MILL MD
21244-5802
US

V. Phone/Fax

Practice location:
  • Phone: 410-298-4642
  • Fax:
Mailing address:
  • Phone: 410-298-4642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateMD

VIII. Authorized Official

Name: SHANIKA LA'TIA BURKE
Title or Position: COO
Credential:
Phone: 443-977-8879