=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376299149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HER MIND HER BODY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2022
-----------------------------------------------------
Last Update Date | 03/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10711 RED RUN BLVD STE 112
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-250-4393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10711 RED RUN BLVD STE 112
-----------------------------------------------------
City | OWINGS MILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21117-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-250-4393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | LACHRISIA LORRAINE MATTHEWS
-----------------------------------------------------
Credential | LCPC
-----------------------------------------------------
Telephone | 202-250-4393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------