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General NPI Number Information
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NPI Number | 1215841804
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Entity Type | Organization
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Legal Business Name | MENTALLY EVOLVED LLC
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Dates
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Enumeration Date | 09/30/2026
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Last Update Date | 09/30/2026
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Provider Practice Location Address
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Address Line | 100 WEST RD STE 300
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City | TOWSON
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State | MD
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Zip | 21204-2370
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Country | US
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Telephone | 410-832-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 100 WEST RD STE 300 PMB 17673455
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City | TOWSON
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State | MD
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Zip | 21204-2370
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Country | US
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Telephone | 443-939-4422
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Fax |
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Authorized Official
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Title or Position | CRNP-PMH
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Name | MRS. TYIES ALEXANDER GOINES
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Credential | MSN, CRNP-PMH
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Telephone | 443-939-4422
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State | NULL
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